NATIONAL HEALTH POLICY - 2001
Item
- Title
- NATIONAL HEALTH POLICY - 2001
- extracted text
-
Hf
GOVERNMENT OF GOA
First Meeting of
National Population Policy
►
at
New Delhi
22nd July, 2000
Address by :
Dr. Suresh Amonkar
Hon’ble Health Minister
Government of Goa
It gives me great pleasure to
participate in the first meeting of the National
Commission on population here in New Delhi
when all the States and Union Territories
come together to deliberate on India's
Demographic achievements and future
strategies thereupon to control the
population growth and improve the quality
of lives.
»
»
It is a need of the hour when 16% of
the world’s population is in India spread over
a just 2.4% of the global land area and if
the current trends continue India may
overtake China in 2045 to become the most
populous country in the world. Therefore
its time to address the unmet needs for
contraception, health care infrastructure and
health personnel and to provide integrated
service delivery for basic reproductive and
child health care. It is time that we bring
our TFR to 2.1 by 2010. It is time that we
achieve a stable population by 2045. We have
to look at the country as a whole and all
the states and Union Territories thus
contribute towards this achievement.
Goa a small state on the west Coast
of Indian Peninsula has achieved a decade
back all the goals that were envisaged for
the year 2000 and this beautiful state will
always try to contribute in one way or the
other towards the national achievements of
the goals set in the new National Population
Policy 2000.
Prior to liberation, Goa had a low profile
of socio economic development and only
hospital oriented medical relief was available
to the people to a very limited extent that
too in urban areas. The post liberation period
has witnessed large-scale expansion of
health services to the very door steps of
the people under the cover of primary health
care. Efforts are being made for
consolidation of the existing infrastructure
for improving the quality of health services
delivery. No doubt, high literacy rate, high
per capita income, easy accessibility to
health
infrastructure
and
health
consciousness contributed towards this
achievement
2
<
The Family Welfare Programme was
launched in this state in 1962 soon after
the liberation of Goa and the programme
was always implemented in Goa keeping
in view the national policy. Today with the
introduction of Reproductive and child
Health Services, the approach is shifted to
community needs assessment approach to
address the unmet needs of the community.
«
V
I am proud to say at this juncture that
Goa has been successful in bringing down
the birth rate from 24.45 per thousand in
1962, when the programme was launched
after liberation of Goa to 14.3 per thousand
in 1999.
Besides the Family Planning strategies
there are also other factors that have
contributed towards this low birth rate.
Inspite of the eligible couple protection rate
being low, this state could achieve the low
birth rate which perhaps is the lowest in
the country. Goa has unique pattern of child
bearing, with very low fertility below the
age of 24 as a result of high average age
at marriage and the late initiation of child
3
bearing. The mean age of marriage is 24
to 25 years in Goa while in 1971 it was 21
to 22 years.
Goa has attained below replacement
level fertility. National Family Health survey
in 1992 had shown Total fertility rate as 1.9
but the provisional report of the second
similar survey in 1998 has shown a decline
to 1.7 per woman. Religious differentials
are less prominent. Another striking feature
of fertility in Goa is its uniformity in urban
and rural areas.
Every pregnant woman is registered
in Goa for antenatal care. The median
number of antenatal care visits was 7 and
the median of gestation age for the first
antenatal care visit is 3 months.
Besides the infrastructure under the
Government sector, a huge network of
hospitals/Nursing homes in private sector
has also contributed towards achieving
almost 100% institutional deliveries in Goa,
and this has lowered the maternal mortality
rate to almost negligible that is 0.25 per
4
4
I
thousand pregnancies. Its time now that
we think of improving the quality bringing
down the anaemia cases to minimum and
increasing the birth weight of the new borns.
The specialized paediatric services
have been extended to rural areas and this
in itself has helped in bringing the infant
mortality rate to almost 15 per thousand live
births. The Child Health and survival
programmes are strengthened at all the levels
taking care of all diseases like diarhoea,
acute respiratory infection and other vaccine
preventable diseases. The coverage of
routine vaccinations under 1 year of age is
over 95%. Special strategies have been
worked out to vaccinate the children in slum
areas, labour force concentrations, and other
floating populations migrating to this state
on a large scale frequently. No polio cases
have been reported in 1999 and during the
six months of this year. Intensified Pulse
Polio Immunization is successfully
implemented to see that every child received
5
the polio dose and the same will be done
on 10th December 2000 and on 21st January
2001 during the last cycle of Pulse Polio
Immunization Programme.
Knowledge of any method of family
planning is almost universal in Goa and the
family planning methods are well accepted
by all the religions. Quite a sizeable
population also go for the natural methods
of family planning. However the male
sterilization method is still not well accepted
in Goa. However efforts are made to step
up the male sterilizations with the
introduction of Non Scalpel Vasectomy. The
preference of having a son as the next child
is not very strong in Goa.
Of all the sexually Transmitted
Infections, HIV has been tormenting this
state over the last 10 years and all the IEC
and media channels have been strengthened
to bring about the change in the
behaviours of the young cross-section
6
<
I
of the society. Adolescent education is
implemented to the fullest extent to keep
away all the lifestyle disorders besides
strengthening the health delivery services
in the management of sexually transmitted
infections.
With this brief scenario of Goa, I would
once again like to stress that even though
Goa has achieved the goals envisaged in
the national population policy this state will
always strive to sustain the same and
implement all the strategies envisaged in
the new policy. Modalities will be worked
keeping the local situations in view so that
the quality of health delivery and the quality
of life is achieved to the best levels possible.
The Non-Governmental Organizations and
all other Government Departments will
definitely be involved in this planning and
implementation of this policy.
With this, I thank for giving me this
opportunity to address this distinguished
7
gathering and always assure all co-operation
from Goa state to make the implementation
of National Population Policy a grant
success.
Thank you.
i
8
Hp
PrriXR
OYO
1
HHf-
DRAFT NATIONAL HEALTH POLICY
PARTI
A Intro duction
1.1 The primary aim of good governance is enhancing the welfare of the people by pursuing
policies that enable every citizen to live long and productive lives. It is for tills reason that good
governance lias always been (Esociated with the promotion of health and education, and
development with provisioning every individual with basic capabilities to live a life free from
hunger, disease and physical suffering
1.2 The unique feature of our haittige lias beai according primacy to ailiancing a state of well
being and prosperity by emphasizing the prevention of disease and promotion of good health as
cornerstones of the systems of medicine practiced. We need to endeavor to continue to preserve
these sound principles that guided our forefathers.
1.3 The Constitution Of India does not declare health or health care as a Fundamental Rigjit
Yet, most court rulings have interpreted die Articles of the Constitution dealing with the
protection of life and liberty as including the rigju to health as a Fundamental Right, casting a
special obligation on the state to safeguard the right to life and protection against medical
negligence
B: Preamble
The National Health Policy of 1983
21 The National Health Policy7 was a result of the cormutments made by India to achieve the
goal of Health For All at Alma Ata in 1978. It was also a reflection of the times when high
priority was accorded to social justice and poverty eradication
22 The National Health Policy was sei in the backdrop of the successful eradication of sitmII
pox and plague; a substantial reduction in the incidence of malaria aid cholera and an increase in
life expectancy7. The main focus of the policy7 was to increase access to health services in rural
areas, reducing the high levels of maternal and infant mortality and conuxuiicable diseases,
establish early warning systems and widen health. action by making health central to social
development and poverty alleviation These goals were to be achieved by the rational
development of the required human resources and die active involvaiient of civil society.
The National Health Policy of
resulted in sihstantial efforts to enhance access of
rural populations to public health services by establishing a large network of hospitals,
dispensaries and health centers. Initiatives were also taken to inprove maternal and child health
and reduce prevalence of communicable diseases. The eradication of guineawomi and the near
elimination of leprosy and polio, wiiich till recently’, accounted for hj^i levels of morbidity7 and
mortality, have been some of the impressive achievements.
23 Yet, the system of health care continues to be plagued with problems of widening inequity7
in access to basic heaidi care services; unacceptably high levels of human suffering on account of
communicable and infectious diseases; a disturbing increase in non communicable diseases due to
changes in lifestyle; and increasing demands as a result of a burgeoning population and
demographic changes. The emergence of MV / AIE6 is worrisome as ail projections indicate a
ll^ \
sharper increase in disease burden in tiie next decade The poorly regulated health system hse
also undergone dramatic changes with the rand mishrooming of a private sector that is seen to be
responsible for rising costs. The widening differentials in the levels of development within and
among the different parts of the counuy require new’ approaches, greater decentralisation and
delegation of responsibility. Ofconcern is the gradual deterioration of the health delivery system
and the inability of government to effectively implement the national disease control
programmes. Of greater concern is fragmentation of die service delivery into disjointed and
uncoordinated expressions of specific diseases rather than an integrated and holistic response to
the needs of a patient, (Box - NsS data)
24 With die rapidly changing macro-economic environment that poses several risks and
opportunities, the fliture holds great challenges. The forces of globalization, liberalization and
privatization, die technological advances hi the area of medicine and telecomuniications and
changes in value systems will profoundly' impact on die ability of die poor to live healthier and
longer. But these charges can also rmke diem more vulnerable and less accessible to the health
system as sqiliisticated teclmolo^' is expensive and beyond die means of most poor.
25
Managing the impact of the new paradigm will require a dynamic vision and bold
action Digrnccring die changes widi out sacrificing die basic principle of no citizen suffering for
want of an ability to pay will require building capacity to harness the energies of the people. It
will also require restructuring the existing systems with new ones that would be rmre suitable for
coping widi emerging demands and rising aspirations. Tins process of charge would need to be
brought about byfocussing on the development of capacities within the health systems at ail levels - the central state and district
26
Every citizen has the fundamaitai right to heakh and liberty and be able to contribute to
society. It, therefore, stands to reason, that all citizens must be able to achieve access to health
care services, without differentiation in qualib/-. In creating such conditions, we believe that
Government has a positive and proactive role to play.
2.7 The revised National Health Policy is an effort and a concerted attempt at enabling
government fulfill its social obligations. It aims to establish a caring and humane system of
health care, guided by concerns tor equity, efficiency and quality.
Objectives
3. The core object^es of the National Health Policy are to
• Reduce the overall burden of disease, both, communicable and non comnunica: bie diseases
within the next ten years to more accqrtdble levels; (Pox ofgoals)
• Inprove delh’eiy’ systems in a manner that will ensure equitable access, quality of care and
effic iency;
• Institutionalize systems for sustained health action through effective intersectoral
coordination;
• improve the quality of educ ation and training of the technic ai
manpower engaged in the provisioning of health care:
• Establish systems for encouraging appropriate technology and technology audit will the aim
of achieving high quality care but at affordable and reasonable cost
• Earmark KB'o of the budget at central and state level for research in areas of national
importance and futuristic cone air
• SirenglheR the capacity of the government to regulate effectively;
• Institute appropriate frameworks that will enable the creative particpation by all constituents
of civil society,
• Ensure,that the health system has as its primary focus patient comfort, and-is-guided by core
values of excellence, conpassion, respect for life and hunwn digjiity.
PARTH
Bask Health Care For All
Disease Control - A Renewed Focus
4.1 Infectious and communicable diseases caused on account of em.Tronmental pollution and
poverty entail adverse consequences for the growth and development of the country. The
resurgence of malaria and dengue, and the emergence of new diseases such as HrVATDS has
inparted a new sense of urgency to the programmes related to the control of vector and water
borne diseases, TB,HIVAIDS, hqjatitis and vaccine preventable diseases. In xiew of the
widespread deprivation disease and ill health cause on the lix^es of the poor, elimination and
cffectix’e containment of communicable diseases within tolerable limits is increasing]^’ being
recognised as not only a moral but also an economic inperatwe.
4.2 While current efforts will ensure the elimination of leprosy and polio within the next five
years, cnxTronmental and social factors impose severe constraints for die elimination or
eradication of Malaria, TB or HIV/ADDS. Therefore, efforts will be aimed at reducing
transmission of disease, reducing mortality’ and morbidity’ by ox’er three quarters, ensuring
minimising drug resistance and containing disease at acceptable levels within the next twenty
years. (Box of Goals)
Strategy
4.3 The control of X’ector borne diseases such as Malaria, TB, HTMAIDS, and '.xaterbome
diseases such as diamohoea and respiratory’ infections, elimination of leprosy and vaccine
preventable diseases will continue to dominate the health agenda for the next decade; as these
diseases account tor more than half of morbidity and mortality, particularly among the poor.(
Disease xvise strategy’ approach in Armcxure).
4.4 Due to the x^astness of the country, the x^aried geographical and climactic conditions and
grooving drug resistance to the first line drug^, extensive technoeconomic and scientific analysis
of the disease causation, treatment and case irmagcment practices, will be undertaken. Such
-V
5
studies assume great importance in view of the high 'prices of the new drugs, making cost of
treatment more expensive. The overall attempt will be therefore to study the best practices and
have more than one set of models to be applied in accordance with local need.
4.5 Experience of the past fifty yeans has brought out tlie serious Imitations in the vertical, top
down and centralised approach adopted in the implementation of disease control programmes. In
view of a growing perception on the need for greater decentralisation in the planning, designing
and financial functions to the state and district levels, the Central Government has, in the recent
past, bean encouraging state governments to constitute autonomous societies to facilitate such
delegation and decentralisation The limited experience available of management tlioi^h
decentralisation has been positive
4.6 Given the wide differentials in health status and the institutional capacity to bring about the
epidemiological shift amoqg states, the goals laid down for disease control will be achieved by
adopting flexible approaches for the implementation of the strategies, namely.
• Establishment of a Technology Mission for Communicable Disease Control in the seven low
performing states of UP, MP, Bihar, Rajasthan, Assam, West Bengal and Orissa; and
• Greater decentralisation of prograrrmc implementation to enable a more horizontal and
integrated approach to health care in the remaining states.
Technology Mission for Communicable Disease Control
4.7 As nearK tliree quarters of* the disease burden on account of the infectious and
communicable diseases is concentrated in the states of Bihar, Rajastlian, Madhy a Pradesh, Uttar
Pradesh, West Bengal Orissa and Assam, progranrne management strategies and the pattern of
financing will be rcfomxilatcd to be inpknxnted as a Technology NIission in these seven states.
The Technology Mission for Communicable Disease Control will be provided the administrative
and financial authority and have adequate technical capacity to undertake the inplcmcntation of
the disease control progranmes in accordance with the guidelines. Bridging of infrastructure
gaps, provisioning of inputs and close and effectives field level monitoring will be ensured by the
Technology Mission. This approach will also enable direct release of finds, quicker
implementation, avoid duplication and enable effective monitoring Such focus is justified on
grounds that the health systems need strengthening for ensuring minimum quality, and the
magnitude of the problem being substantial (here is a great necessity to have a framework that
will ensure better coordination and integration of inputs and service delivery.
Decentralisation - an approach towards horizontal integration
4.8 As vertical programming is resulting in fragmented implementation causing serious
distortions, in the states which have achieved a measure of stability in implementat ion of disease
control programmes, the process of planning and implementation will be decqntralised to the
district level The PHC located at 30,000 pcpulation will be the unit for communicable disease
-
«
control and public health action This process of’decentralLsation will be based on the following
conceptual framework:
Every’ district will be required to formulate District Health Plans, based on an analysis of the
district disease profile and resource mapping
• The Medical Officer will be directly responsible for the achievement of goals laid down, for
which there vvillhc adequate administrative and financial delegation ofpower.
• Devolution of funds from the central and state governments to the districts will not be
progranrnatic or schematic , but be in the nature of block grants in keeping with the
requirement of funds indicated in the Action Plans;
* Formulation of a package of incentives and disincentives to ensure conpliance to financial
discipline and programme guidelines will be developed.
4.9 Decentralizing the functions of planning development of strategic approaches and
procurcnxnt of drugs and equipment to the districts, will ensure a horizontal and a more
integrated approach to disease control. It is believed that such an approach will enable focussing
on the high risk areas within the district, reduce duplication and enhance a more efficient use of
resources and stimulate creativity and participation of the local conrrunities. It will at die same
time make the local health authorities more active partners and more directly accountable and.4
responsible
Revised Role of Central Government In Communicable Disease Control:
4.10 Responsibility of theCentral Government will be to lay down input specifications,
treatment protocols and quality standards. It will also be responsible for tronitoring and review;
undertaking of studies to assess adherence to and implementation of guidelines pertaining to
quality and standards; training of manpower and research The Central Ministry will be suitably’
restructured to strengthen its capacity to regulate in an effective manner.
4.8 7’he shift in strategy will be gradually inplemented, spread over three vears. The pace will
depend on the readiness of states and districts. The pro cess of decentralization will be prefaced
with intensive training in the upgradation of skills in the planning, resource nipping budgeting
and epidemiological aspects of disease control
Non Communicable Disease Control - An Area of Concern
5.1 All projections indicate that if the currait levels of uibanisation, present lifestyles and
habits remain unchanged, in tine next, two decades, there will be an estimated fifty million
diabetics and nearly 245 for every 1 0,000 person suffering from heart diseases.
of all
cancer, cardiovascular diseases and hypertension are reportedly’ on account of tobacco addiction.
The number of persons dying of injury and lung diseases such as asthma will continue to
increase With tlie longevity of life, inpaired vision will continue to be a concern. With
3
increasing stress and societal pressures, mental health will emerge to be a serious public health
issue affecting yout^g men and women in the prime of their lives.
Strategy
5.2 Strategies to reduce and contain non commmicablc diseases will consist of the fbllowipg
conponents:
• Formulate a National Non Communicable Disease Control Programme that will be responsib le
for undcrbikiiig activities related to the prevention, promotion and curative activities of
lifestyle diseases, namely', cardiovascular diseases, cancers and diabetes.;
• Highest priority-' will be accorded to health education and health promotion activities aimed at
prevention and the development of cost effective and affordable practices ofcare.
• Develop strategics and action plans in consultation with the implementing authorities at the
state and district levels for bringing down prevalence of blindness., mental health and for
accidents and injury prevention and treatment;
* Increase budgetary sipport to implement the control programmes;
9 Priority will be accorded for reduction of mortality by providing anergency care consisting of
immediate access to first aid. facilities for stabilizing the patient and ambulance services for
transporting patients to health facilities;
9 Develop the rojuired manpower, such as cytologists, psychiatrists and psychologists, to cop
with the increasing demand for such diagnostic and treatment services:
• I^ay down standards., systems for e<irk screening and diagnosis, case management and
treatment protocols of non communicable diseases and quality’ assurance guidelines to be
applicable to the private and pub be sector tliroughout. the country;
• Establish in the Central Crovemnient a High I^evel Committee to undertake techno-economic
studies to study and monitor tire utilisation of technology and the price factors, lor promoting
low cost options and other cost containment strategies, inc hid ing teclmology audits.
• Strengthen the piblic health delivery system to provide free treatment to the poor and those
who cannot afford private care;
9 Make the Area hospital located at every 500,000 lakh population the unit for non
communicable disease control activities . namely disease surveillance, health education,
training, diagnosis and primary screening and rcfcrrel etc.
* Establish Cancer registries in every state and clinical cpidaniological units in every teaching
hospital
5.3 To sustain and ensure the inplcmcntation of disease control programs at the state and
district level priority will be for strengthening and establishing capacity for disease surveillance
and qridaniology. GOI will facilitate and assist states to establish epidemiological and planning
units at the district level for a period often years or as per need.
5.4 Financial devolution to states and districts will be based on both, considerations of
population as well as projected disease burden and the requirement of resources thereof
Revamping the Health Care Delivery System
Rural Health Sendees:
6.1 Acliievanent of disease control goals is contir^gcnt on die fuiictioning of die health
delivery system Despite the impressive array’ of sdbeentres. prirrary health centres and
coniinnity liealtii centres, utilization is sub optimal, widi 80/6 of the people seeking health care
from private practitioners. Surveys show that some of the factors responsible for the poor
functioniitg of die primaiy heakh care centres ate inappropriate location iiadequate
infrastruchre, non availability of drugs, equipment or sipplies, large number of vacancies, poor
supervision, indiscipline and absence of accountability. Further, in view of die wide .
differentials in the pace of development among states, within districts and among cornrunities,
die normative population based approach adopted for die establisliment of die facilities is
inadequate, necessitating corrective action. Finally, despite sustained attempts, the reluctance of
doctors to work in primary heakli centres located in interior ar eas continues to persist seva*ely
damaging the credibility' of the system The nonflinctioning of the primary health care system is
one of die main reasons for diejnushroomii^g of a variety of rural medical practitioners, who
though unqualified, command a good clientele for want of affordable alternatives.
Strategy:
6.2 The first step for an examination of the need for restructuring the delivery of health
services in rural areas will be resource mapping Such mapping of facilities in die public and
private sectors will help in determining the areas, locations and the communities having no access
to any liealdi care services on account of distance and plysical baniers. Adequate flexibility will
be provided to the states to establish, close down, re-deploy or expand the existing facilities and
personnel, keeping in view the need. GOI will assist states for conducting such surveys and
development of geographic information systerrE.
6.3 States will be required to adhere to certain nomas for ensuring equitable access. However,
there cannot be aiiy stardardised i»ni6 applicable tlroqgliout the country. Nomis for locating a
facility would need to be guided less by population coverage and nnre in terms of local health
needs and die tine taken for accessing diat stavice. Thus, die iiomis could be a trained paramedic
( a midwife or a counsellor) available for every 500 families and within 15 minutes distance;
access to emargency* care for every 5,000 families within 30 minutes distance; and inpatient
treatment facilities and the services of a trained rrridwrfe / .eynecoloeist for evay 20.000 families,
within less than one hour distance
6.4 To overcome the problem of chronic absenteeism of health woikcrs and medical doctors,
option should be given for reviving the old system of family ph>?sicians. This concept consists of
a licentiate of medical practice (LMP) to be working at die village level for servicing the needs of
a maximum of2.500population. The'Tamily Doctor” will be indicated for a defined population
and area. Rarancration will be on a fixed fee' per capita basis, will flexibility for cliargiiig for
other than specified services and as agreed to by the comnunity. The ED will be provided with a
strict protocol and guidelines ofprocedures and services that can be allowed to be performed and
delivered: any deviation being construed as malpractice The ED will also be required to refer
patients for all cases beyond liis purview, with an incentive of additional payment for every case
of a timely referral.
6.4 It is envisaged that wit h the institution of the “ family doctor,” access to die package of
btsic health care services will be inprovod. As the village based family doctor, he will bo
responsible for a range of functions, hitherto being provided by the health workers and PDC staff,
viz. chlorinating of wells, testing ofblood smears bfall fever cases for detection of -malaria cases,
supervision of TO treatment as presenbed. identification of refractory errors, immunization and
anlenabil care, treatment of STD’s and minor a,ilmcnts etc. lie will bo also required to maintain
the cause of death and birth registers and report all cases of rrorbidity to the PflC He will act as
the depot holder a**! will be entitled topi escribe only listed tings. lie will bo required to work
under the supervision ofthe Medic al doctor Of thePHC
6.5 With the establishment of the “Village Doctor" states cm take a view regarding the number
and location of tliofanalo and male health workers. As there will be no rctraiclimcnt of workers.
States will be pennitted to re-<lqfloy the female health workers to fill the gaps caused by the
absence ofmale workers. Choices can also be made in some areas of converting the male worker
into a laboratory teclmician by providing him with apprcpriate training. There will also be no
need to insist on a fixed facility for a subccntr&
6.6 The efficacy and the utility of the PIIC as an institution oflb ing inpatient treatment on a
twenty four hour basis has not been demomtrated. Therefore it. is envisaged that the PHC be
developed as a polyclinic and notified as the primary unit for the inp lamentation of all public
health programmes, namely TO, reproductive and child health Malaria, and other vector and
water borne diseases and trauma It will be provided with communication facilities such as
telephone, wireless sets etc.and vehicles. The objective will be to provide timely care by
transporting the patient to the hcaltli center, treat and stabilize the patient and transport to the
CHC for further treatment if required.
6 7 ThePHC will be manned by a doctor trained in public health and family medicine or by
paramedics, with additional training in public health. It will bo a mandatory iv^uircniUu for all
staff working in thePHC to undergo a 6 to 8 weeks training in public health and emergency care
prior to taking charge of the post.
■
6.8 The PHC could be a government, fac ility or a private / non-govemment facility wi 11 ing to
provide die package of services a5 per rates specified.
6.9 The CHC will liavc a minimum of 30-50 bods and consist of 4 -6 doctors and support
sendees such
full fledged laboratories, blood bank, operation theatres etc It will be the apex
of die pyramid ofdie basic health care system, providing clinical back ip, required for enhancing
the credibility of preventive health care The d<5 will be the hub of the system for providing all
logistic sipport and will be effectively networked with transport vehicles, telephone and
computers. It will be r’bandatory for a woman doctor to be posted at the CHC. It will also be
required for <111 the doctors and die paramedic staff to stay within the premises.
6.9 The dIC will act as the gatekequr and the first point of the referral system, entry to circa
or district hospital being only on the basis of a referral from the CHC
6.10 Ideal k, the CHC should be a government, fac il ity. However., wherever there are chantab le
and non profit institutions with a h^i reputation of public service established, these will bo
identified as die CHC for the notified area As CHCs they would be eligible for financial sipport
from Government, subject to conditions. This will help reducing cz<pcnditurc and avoid
duplication.
6.11 In several areas there are nultiple institutions - dispensaries, taluk hospitals., as well
CHCS” etc In order to reduce diplication die redundant institutions will be redeployed for
providing the pyramidical structure
6.12 The strengthening and the quick establishment, of the CHC will be from the process of
restructuring as indicated cbovo, which will free resources to be ro-dcployal at the CHC. 2005
will complete the exercise of establishing CHC’S.
Urban Health Services
7.1 One of die drawbacks in health policy has been the virtual absence of a framework for
urban health care service delivery. Danograpliic trends suggest that in die nezet two decades over
forty percent of the population will be residing in urban areas. The implications to public health
of such increases in population without a corresponding expansion of the infrastructure arc
serious and require immediate attention Contrary to comron belief’ the urban poor are as
unhealthy and as sick and dicrcforc, as much in need of access to affordable, good quality care as
rural populations The cities and towns also have poor sanitary’ conditions due to poor waste
disposal systems. Ovcrciowdipg, lack of regulation on die nunba of vehicles and increased
environmental pollution are the causative factors for a large number of dead's on account of both
accidents, injuries and respiratory infections.
7.2 The urban and sani urban areas of the country have a largo concentration of the private
sector The private sector is hiehly heterogeneous, ranging from corporate hospitals to charitable
trust hospitals and solo practitioners practicing all systems ofmedicine. In view of the incentives
extended by Government excellent facilities have came up in the private sector However, due to
lack of any regulations, standards or systems of accountability, there are a nuirber of instances of
misuse of technology, malpractice, overcharging etc. Conplaints have ranged from excessive
diagnostic tests, ovennedication or irrational use of expensive drugs, to negligence and unethical
standards.
Strategy
7.3 Due to the availability of a large network of private practitioners with good facilities, there
will be a lesser need to establish secondary and tertiary facilities in the government sector Tn anv
laido-savcdpockds, incentives will be extended for private sector to establish curative facilities.
7.4 Health Posts will be established in all notified slums having 2500 population or within one
km distance or 15 minutes bus journey, for providing preventive and primary care services, fhe
Healdi Posts will be manned by a trained public health worker and a conservancy staff lor
overseeing all aspects ofpub lie health and hygiene
7.5 Every permanaU resident in the urban areas will be required to take a health insurance
policy.
7.6 The poor and the indigent who cannot afford a policy , will be eligible for free treatment in
government hospitals. Every private hospital will also be required to earmark a percentage of
their facilities for free treatment as a part of their social responsibility. These ‘free’ patients will
be those reterred to by government facilities / or on basis of adoption of a defined area families
etc. as indicated by the municipal authorities.
7.7 The Dqxirtrncnt of Health w ill work closely with Municipal authorities on lour major
issues of priority concern in urban areas: scientific waste disposal systems for ensuring healthy
settings, sanitation systems, water quality surveillance and health education; malaria and other
vector home disease control progranines and rigorous mplementat ion of the regulations related
to food safdy, phannaccuticals and malpractice This collaboration will be achieved by:
i) Training of Municipal cornu vancy staff and public health a^ginccrs on health impacts
unhraIthv environment •
ii) Public health education and advocacy;
iii)Establish a Gxjrdination C ommittee for Public Health and Sanitation (CX3PHS) consisting
of health officials, nunicipal authoiilics, I tcspiial superintoidents of major hospitals and
peoples representatives on the inpiementation of the various piblic health measures,
collection and disposal of solid and dangcrovS waste, which will bo accorded a vary hi^i
priority'
7.8 On the basis bf polluter pays pnncple, all hospitals and health establishments will have to
pay the cost for waste removal The Municpal laws will also be amended and made more
stringent for paialis ing any violation of the guidelines related to waste disposal.
£4
7.9 All hospitals and health facilities will be netyvorked for the. purpose of establishing
hospital waste disposal systems, such as incinerators, shredders etc. depending on the volume of
waste.
PART III
Institutional Cai e
Ai ea and District Hospitals
81 Institutional caru will not be fr ee except for die vary poor airi the indigent who arc
estimated 30% of the country’s population
ail
82 Goveninient will continue to establish hospitals for providing secondary care at the district
level and below, for providing good quality health savices to the poor and those who cannot
afford private care
8.3 Govemmett Hospitals will be given administrative and financial autonomy so as to enable
than to raise resources for oBtiring sustainability of the institution. They’ will work under a
Hospital Committee or Board which will consist of a wide representation of all stakeholders.
84 Tlie CHC’s will be networked with Area Hospitals and the District Hospital, which in the
next two decades will be fully developed for providing secondary care. The Area hospitals
located for every 500.000 population and the district hospital will be centers for providing eve
care services, diagnostic services for detection of non-coniwnicablc diseases, counseling for
mental healtli etc. The District hospital will also provide specialist services for patients referred
by the Area Hospitals.
o
c
L>.
Doctors vwikipg in government hospitals will not bcpomittud private practice.
Organi&itioiial Structure for Delivery of Health Services ad District Level
7.1 Tlie District level organizational structure will be revamped to be suitable for coping witli
the emerging challenges and demands in the healtli sector. Rssentialk the structure will consist
of:
— A District Health Board (DITB) under the chairpersonship of the District Collector or an
eminent Physician:
— A Quality Assurance and Certification Board (QACB) consisting of a panel of eniment
clinicians, eminent personalities, citizens, NCO’s etc.
— District Epidaniological, Planning And Surveillance Unit (DEPSU)
7.2District Health Board
The District Health Board (DHB) will be responsible for the resource mobilisation, budgeting,
plannir^g and monitoring of die hcallli programnes in the district The Board will consist of a
wide set ofpersons representing dwerse fields and social groups. It will be required to hiet once
in two montlis. Two mcotii^s will bo open for piblic participation. The agenda and the minutes
of the meetings will be available for public scrutiny on demand and on the conputer.
7.3 Quality Assurance at District Level:
✓
■■ 7
The entire network of hospitals, public and private will be networked by computers, tor enabling
surveillance and quality control by the Qualify Assurance toll to bo located in die district
consisting of leading practitioners of the district The cetf will ensure the implementation of
national standards and review adherence to the nonra pnd protocols laid down lor delivery of
care The cell will also have the mandate to undertake review of the practices “being adepted by
physicians and identify cases ofmalpractice and non ethical conduct
7.4 Surveillance:
The District will have an Epidcniological, Plisnniqg and Surveillance Unit (EPSU), staffed
entirelv bv trained persons and funded by the GOT for a period of 1 0 years. The finds for these
posts will be mobilized by transferrinig of posts sanctioned to the districts /'states under various
schemes in the past or from the licensing fees to be charged to every practitioner in the district
All practitionas will bo legally requirod to inform the unit on all notified diseases in prescribed
formats. This infbnnation will be compiled and disease tracking forecasting and control
mcasUi'cs will be the respoiisibility of the units. The EPSU will also be required to publish the
infonnation for public knowledge, to district authorities for taking action, and to the state and
caitial govcmnients. The iiifomsition furnished by the EPSU will fonn the basis for prqparation
of the District Health Plans The FPSl fe'will be independent and report only to the state and
central authorities, so as to enable objectivity and no bias.
PART IV
Role of Civil Society
9.1 The principles ofdccentralisation, quality, transparency and accountability in the health sector
can be achieved only when there is active involvement of all sections of civil society and an
effective demand for good quality care One major reason for the ills of the prevailingpystcm of
health care in the country is the abseire of such an informed public.
9.2 It will be endeavored to foster arri develop mechanisms for public action and involvement,
with a view to safeguard the interests of the patient, the poor and the vulnerable sections of
society7. People/ energies will bo clianndcd and participation secured by a federated set of
comniaees consisting of the Viiiage Health C ommirices. Hospital Committees and the District
Board The functions of these public committees will be to monitor ethics, quality, pecpie’s
grievances, resource mobilization and peen les’ responsibility tor good health values.
Village health Commiftees
9.3 Securing the support and participation of the local communities and noi^govemmaTtal
organizations tiirougii the Village Health Cornrrnttees (VHC) will be the foundation for building
ip the edifice of information dissemination and collection The VFKTs will be empowered with
knowledge in areas of disease prevention, first aid, ftmiishipg of information about illnesses and
die pi op u auur idai ic c of the health functionaries tic., coniiiiniiy counseling, particularly for
HTV7A1DS patients and the disrhied: transportation of the sick and needy for treatment, and
mobilisation of resources for ensuring access to safe w^ter, sanitation and a hcedtlrz setting For
cffcvlive diacliaige of ilicse fui^tioiib, the VHC’s will also be tiiuotuaged to establish a sickness
timd bv mobilizing resources from the state and central government and local taxation One of
the main f motions of the VH7 wdl! be the preparation of Village Health Plans and monitor their
inp Iciita itat k»i1
Hnsnital Commiftees
Peoples nivoivenTent will also be secured by the constitution of Hospital Committees for ail
CHC’S Area Hospitals and District Hospitals Thexe committees' will review the hospital plans
and nunitor the functioning of die facilities. They will extend active assistance in mobilisation of
resources through user tees, donations, local taxation through the local bodies, government
budgets etc. While the CHC committees will consist of some merrher« of the VHC’S. the
District Hospital Coninittoes will consist of rqjresentatives of the CHC / /Area Hospital
Commiaees.
An Intersectoral Approach to Health Key to Poverty Alleviation
10.1 The health status of individuals and communities are very largely determined by societal
and cultural ^’alues, the most encompassing being the value for life. The compulsions of
iiicrtasiijg needs and clianguig values, iiave uieaied a life -negating env uohiikjil, with ad vase
consequences to the health of the communities. Progress and development have been at the cost
of depleted forests and polluted err.’ironment, poor Ir/giene and waste disposal practices, changes
ill lifestyle and eating Iiabita ail tOgcihci cunuibuimg lm a fctiHrkable inciCsisc 111 uvtlali
morbidilv. f or a poor countrv like ours, medical care is no solution, given the hish costs
involved. Health promotion and concerted efforts to minimise adverse health inpacts by
adoptmg holistic appiMatlicS io dcveiopiikiiL are die oiuy cost effective optioi'6 available. Of
priority7 concern tor such intersectoral cooperation would be in the critical areas of sanitation and
(jsrfe drinking watpr, nutririr»nz poverty alleviation, literary7 nmrrotion and ernSronment A set of
prOpOSCu fiiitidtivOS diO described boiMvV.
Drinking Water Supply and Sanitation :
10.2 Consunpuon ofcontammaied water, and uniwgienic disposaioi waste are causative factors
for a ver/ sdMantia! extent of moriridity and ill health Therefore any inprovement in
^proving these detaminmls vdll have a manifold impact in reducing disease burdai
Water Quality Surveillance Centres:
10.3 In view of its importance to health status, for every one lakh population water quaiitv
surveillance centres will he established, appropriately equipped with instruments for undertaking
tests of water sanpies. Reports of water quality will be published in newspapers and
disseminated to the affected populations on a monthly’ basis. The surveillance units will also be
respons ible for undertaking village visits for the purpose of health education on preventive and
promoth’e aspects ofdrinking water, trainii^ and chlorination of wells / water sources.
10.4 The water quality surveillance centres will be located in the Community’ Health Centres
and will be paid for by the village panchayats, state and central government on a slioring basis.
10.5 At tbe CHC. an inters ectoral comnittee under the chainpersonship of the Block Pramukh
will be constituted. It will consist of the MO, the Assistant Engineer in charge of rural w’ater
supply and sanitation, die head of die vVatu Quality Sui veiilaiit c Unit, Tlic Block DevclopnKiit
Otticer. the Block Education Otticer and one representative of the constituent VHC. The main
fimctions of this committee will be to review the wuter surveillance reports, the nature of and
areas of waier bor ne and disease borne diseases, scavenging and waste disposal and resource
mobilisation reauired tor achieving access to sate water and sanitation, particularly in schools and
health facilitips’
Coordination with I'eciinoiogy Mission lor Drinking Water:
10.6 Al the Caiual and state levels, bell i al the senior policy level as well as at the project level,
the Erinking Water technology Missions will establish Health Ceils , manned by public health
specialists, so that health concerns are in built into the project designs at the planning stage itself
Likewise, a sqjaiate project unit with clear funding and staff will be established in die affected
areas tor arsenic and flourosis control
A T echnohgy Mission for Sanitation
10.7 Access to sanitation continues to be very low. ATeclmology Mission for Sanitation on tlie
lines of drinking \»Mcr will be established and adequate resources provided for ensuring a 1 00?'o
coverage by 201 0 It will be the icspousibiiky of the Mission to develop low cost designs and
under take training in tlie construction of latrines.
10.8 Tovmi PlathLaws will be suitably aufcudutl to ufeure iliat approvals K?t uoifiiiuctkni of
colonies, conplexes or houses will be contingent on an approved sewered disposal svstem being
in place.
10.9 At me state level the Clnef Minister will be the cliainnan of the " Sanitation and Water
snppfy md FiwirotirnmtAl Health Conmittee” and the Minister of Health the vice chairman. The
^onnuttcc will be provided funds by the Ministry of Health for supervision, evaluation and
monitorirtg or the surveiiianceunits and also undertake pub lie uifonnation activities.
Nutiition
10.10 Inadequate information and high prices for certain agricultural products are two reasons for
the various distortions that have crqjt into policies that d^ermine food security and a citizens
access to nuimion While India has achieved seif sufficiency in food production, ya, more man
half the women are anaemic and a half of the under four children are moderatelv or severely
rmlnourishcd. Az mahuitrition is a major causative factor for a substantial burden of disease, it
will be necessary' io ensure dial
't
• Ensure access of the beneficiaries to public health facilities and health programmes;
• Earmark a cenam amount towards a Health Fund towards a corpus, the interest of which
will be used for treatment of ary of the poor beneficiary’ suffering from any of the listed
diseases and requiring hospitalisation;
• Farmark part of the total budget available for rural infrastructure for improving health care
centres and tlieroad networf; so as to facilitate transportation;
• Tn build health in the training programmes for panchayat member or women eroi^s:
* Develop an IEC strategy tliat will help disseminaie health infoniMtion io all die families
covered under the various proeranrnes ofthe department
• Train rural development functionaries on heakh programmes in order to sensitise them on
die linkage between health, productivity and poverty;
5 Through the self uiployrncnt and beneficiary loaning progranrncs, hc^ devekp a network
of ambulances, conservancy and waste disposal systems, village doctors and paramedics
wishing to set up clinics in remote areas etc. by linking recoveries by direct payments to
the banks and financial institutions.
Education and Literacy Promotion
10.13 As children are our future, they are an inportant target group
they mature to become
productive adults tomorrow. Yet policy attention lias been inadequate as even todav’ millions of
children do not attend school, or attend it irregularly on ground of ill health, ’it is ©qualk
disturbing that a sizeable proportion of children, cuffing across ail social classes, are dyslexic and
an equal number suffering from epilepsy and other neurological disorders that can be corrected.
Poor nutrition and physical disabilities are other contributor/ factors for inpaired learning and
puorty developed uogjiilive abilities. All these factors can be corrected pr ovided tire coor dination
between the child, the parent, the teacher and the doctor is established as a result of the process of
inculcating a caring attitude towards children
10.14 Several states have been providing niddav meals lor school children, the successful model
being that ofTamil Nadu., which has helped in bringing about the necessarj? coordination between
different actors in die life of a cliild, resukiiig in improved attendance and die lieald^ growth of
the child, (.jovemment will take steps to make midday meals compulsory in all primary schools
for all children below the age of 14 year?
10.15 In recognition of the importance of sensitising children and developing in diem good health
habits the I Apartment of Health has been collaborating with the Department of education for the
teacliing of topics on hcoltli, nutrkion, sck education etc. in the curricula. Hbwwer, vve
contemplate and envisage a more active coordination which will consist of the ibiiowing
components:
• Declare universal and coirpulsory education and enforce it.
• Provide in every primary and tpper primary school midday meals to all children
irrespective of whether they are enrolled or r^uiar in attendance
• Provide sipplementary nutrition for malnourished children and also establish toe midday
inca^rogranux; with developing good health habits such as1 wad ling hands etc.
• Promote the concepts of Child to Child and Child to Family education. This powerful
concept will be used for pronioting health values such as drinking of safe water,
development of clean and hygienic habits, non consunption of alcohol, tobacco or drugs,
environmental health and nutritiom
• Design and inplcmuii education packages for adulcscaius in and out of scliool, for
dissemination of infbnnation and education on family values, sex education and self worth
throu^i good health values;
• Establish and provide tor conns ell me centres m everv colleee tor students to cope with
chargirg
system? and consequent behaviour patterns, largely on account of the
prop a isity of the youth beiiig vute le to I ITv/AlDS;
• Fstahlkh a Health education cell in all DI EH s for continuons training and materia!
dcvdopii'jBUitou health for headmasters of high Schools iiild teachers ofprimary SCiiOOiS;
• Integrate health as a regular part of the agenda in the village education conmitfees and the
paraii-teachcr coniiiiiUxs.
Role of Private Sector.
i i. i The health sector system m India is a vibrant mix of the public tnid private sector, with die
private sector commanding over fifh^ percent of health service provisioning With the substantial
package offinancial incentives provided in the. mid eighties, die priv’ate sector has developed and
grown on an exponential scale With over two thirds of the medical personnel, fifty percent of
hospital beds and three quarters ofthe market share for cirative services and world class research
and marpjfactmng cap ability in the field of drug production, accounting for almost over 4?'a of
the GDP, the private sector js a r ich resource iliai needs to be nvie fully exploited. Private scctoi
partic^ation can be particularly valuable in toe areas of disease surveillance medical education
and training, provisioning of high quality care, and research in the vital areas of drug production
ai id altei i iativu i i Ku iC ii les.
11.2 Recognizing that an iirregi dated private sector has the potential to create several distortions
due to primacy being accorded to commercial comiderations tlian providing health care services,
priority attention will be to draw up a policy framework for private sector participation. Guided
by cons id erations of minty and quality, the rmin elements of si vh p frnmevwvk will consist of the
following elements:
• Tn addition to toe private practitioners as ‘Tamily Doctors” at toe village level for 2.^00
population, tho private sector will also be invoked in cstablisliing, or, takipg over existing
government PHC s/CHC*s di places where apv^emment is unable to operationalise tor
various reasons after adequate attempts.
• A iocauonai policy baseci on resource mapping ai the district/stare and central levels will be
prepared for identifying the underserved and inadequately served areas for inviting private
sector participation. A package of financial incentives to the not for profit charitable and
trust hospitals, to establish health facilities in such identified areas wiii be fonmiated and a
set of disincentives for locating centers in overcrowded areas.
• A package of non financial mcenwves for undenaking disease surveiiiance^ and
provisioning of preventive and promotive health care services, including mandatory
recording and rqjorting of notified diseases.
• A package of financial incentives will be extended to non profit organisations and non
governmental /charitable trusts to establish .Area hospitals and at the district level
Incentives will range lioiii puicliasing care, to contracting savices of individual
physicians land, tax exenptions. grants for non recurring expenditures etc. Such
incentives '.rill be conditional Such a package '.rill also be o'.’ailable for these hospitals
caniipg in foreign exvliange by do.kit ing the aitapiise as a deaned expoiL
• Financial incentives in the form of grants or tax breaks for promoting and undertaldng
research in the dieas of thug production for addressing notified diseases and national
programmes.
Legal Frames oik To Regulate The Private Sector
• T legislation will be introduced to regulate the establishment of facilities partic^ation in
conmunicablc disease control programmes and .during opidarnics ari emergencies,
monitoring of record keeping and transparaxy in billing procedures, licensing of
equipment and assessment of technology for the purpose of promoting the rational use of
drugs and technology, conteomit of cost and aiploymsit of qualified pasoimel in
accordance vvnh rules and grievance redressai systems etc.
* Establish an Independent Conxnission for die EstabEshment of Standards, consisting of
uiiuitui physicians and public heaiih expens for laying down and rrunkoring adherence io
minimum standards and accrediting hospitals and facilities The Commission will also be
required to
dov.n protocols for qualit’/ in treatment and patient care and ensure their
aiiuicanail uuuugii Uaiuing, pea icvicws and such rigorous systairs of medical audit.
• Amend the Medical Council of India Act to strengthen its capacity and ability to
effectively i tgUiate die cbuibiisimklii of medical colleger, clibuiu ii jui c Sii iljgdit btaiidai ds
for the registenng doctors and ia\’ down a system of periodic renewal oi licenses b®ed on
certain criteria.
•
the Act will also provide tor a Malpractice Fund to be established with grants from
C^vemment and licensing fee^ for conpensating pH^irims xwongk' accused of
malpractice and the patients who have suHered on account of negligence. Such a step
would help increasing a measure of accountability among the medical conmunity as well
as enhance its stature as a responsible body committed to patient care This measure is also
expected to proride security to doctors discliarga^g tlieir duties and reduce cmy tendency to
practice defensive medicine
° For snablii^g hospitals haring less tlian 50 beds, diqg?x>stic centres and blood bari-^
established one year prior io rhe dare of the new regulations laying down standards, five
year grace period will be given for them to improve and ipgrade their facilities to national
norms and standards. For this a fund will be created for proriding soft loons.
• Amaidmau of legal provisions for facilitating public sector facilities to engage on
contractual basis, the private sector for providing critical sendees such as security, waste
disposal ad conservancy, transport and comnnnications, tnaktenance of facilities and
equipment and other such ancillary services etc.
* Suitably amend die Consumer' Protection Act and the Indian Penal Code to cover* all
categories of practitioners, provide for suitable corrpensalion and lime bound redressal of
patients corrplaints
• ConsuiiM Foiuuk will be csiabksiiud in ali disiiicis iui piuviding financial assfsiaive io
poor patients for engaging legal services for seeking redressal from the courts and also
conduct awareness canps7 training programmes among the police officials, piblic as well
as ufcnjbdb of die legal profession a^alirsi any taiua*zy io liaiass liKuical piaLiiiionci s.
Such a step is necessarv to ensure and maintain the sanctitv of the doctorsatient
relationship.
PARI V
Medical Education and Iluinan Resource Development for Health
12 1 Projections indicate that in the coming two decades, we will need to produce a number
of nodical and paramodival personnel to fulfill our rcquirarcnl Further, wo will need more to
meet the growing demand for Indian personnel in fbreigri coumries.
122 Ag per tlieprojections, on additional.... institutions would need to be established roquiiiiig
an csimmed .... crores nivesuTieiu.
123 Tliero is growing concern about the deteriorating standards in teaching institutions, due to
consiricuxi capacity, die commercialization of education, weak supervision by the Medical
Council of India and the absence of systems to enforce a minimum level of standards
124 The policy issue is uiacfurc nut fiuilia privatisation of njtuicai education but die
development of institutions and systems that ensure adherence to standards and a pursuit of
excellence.
12 > For the purpose ol ensuring quality and standards a Health Education Commission on the
lines of the Lhiversify Grants Commission will be established for prormting plr/sicnl standards
for quali^' in the training of the medical and non-medical personnel Tne Ilealth Education
commission wiii be provided witli a corpus of Ks. TOUU crores to provide soft loans to teacinng
insfit’^ionc:
iporqdinn facilities evpmding :md strengthening infrastrnctjire
12o Ail medical and paramedical training institutions/colleges will be autonomoiE, placed
under a Roard ofdirectors^ consisting of enTnent persons ofstanding These colleges will have to
be affiliated toUniva sit^ of Health Sciaices vdiich all states will be aicouraged to establish
12.7 The Hwersity's will conduct the examinations for the medical and non medical training
colleges affiliated to it /i certain percentage will be for internal evaluation, to ensure that tip,
individual colleges are allowed room to pursue excellence.
127 ?d! Teaching Institutions will be given time to obtain accreditation by a National
Association for Accreditation of Medicai Education and rieaidi Sciences. The inAAMEHS will
consist of eminent physicians and scientists of national standing The MCI wiii also be
represented on this Committee. With hidler weightages such as internal evaluation, faculty
devdopmuil, rewarding of merit, in place of automatic promotions etc aimed to improve
excellence in teaching standards etc, overtime, the colleges wiii gam rhe required credibility to
award their own degrees
12.7 All teaching institutions will be given a time frame by when uie^ iiave to obtain
accreditation from the Accreditation Council for enabling their students to practice in the country
12,8 CuiUinukig Medical Education Ibi ail duubuns will be vonpulsoiy and will be a icquiianciit
for renewal of license everv 5 veara.
129 in iccugimiuii of uic need io ujtike iiiccuulcuiuiiiof dc^iOib aiudy mg MESS icievciiii mu
ral needs, a scheme called ROME was introduced m . .. Years of rnplementine it has shown to be
flawed. In
of the increasing demand f?r doctors in rural areas, capable and skilled to
address uieii daikinds a uiree pronged strategy is aivisaged .
Pevise the cnrr’cnlnm to provide for specialisation in public health and family / corrm mity
medicine and gcriairic care for doctors wanting to work in Pike's and CHC'S. For those
desiring to specialise and work in nospitais, post graduation in the area oi specialisation will
be a requirement. Roth the categories of eljgib ility will be exclusive and not interchangeable
Srudems vviii also oe given the option to study a MD course m integratea Medicine consisting
of all system? ofmedicine
Ail students wiii be required to work for one year in a PHC/CHC/Area hospital or Di sinct
Hospital for being eligible to take the N1D course / obtain a license to practice / go ebroad /
MBBS degree certificate.
rural placement s will be made by the Central / State
Government
12.10 All States will be required to- constitute a Teaching subcadre. Teachers in Medical
Colleges will liavc to obtain a dcgruti'diplonti in Medical Toclinology vvidiin 5 year s of service
for bens conftnned.
12.11 Private pi de uce by Tcaciiiiig Faculty of medical colleges will uc baiuieti. Financial and
nCn financial incentives will be provided to make the teachjng profession attractive.
1212 Tiie Teacher will be given a iiigjra' priority in tern® of facilities,, allowances and a
package of incentives to ensure that the best and the most conxnitted get into this profession
12.13 Rvcruitincnt of kaciiaa will be rigorous and based on aptitude and ruscatvh work done,
iheir evaluation and promotions will also be rigorous consisting of student evaluation scores:
research wrk and pihlications; and examination by outside experts, including the peer groin
12.14 The fee structure for medical education will be laid down by the Education Commission
with limited flexibility for medical colleges to lety any estra cliarges. Action will also be taken
to provide lor ioans at subsidised rates tor enabling rhe education of students who have obianieu
admission but belong to families having less than a certain income limit
1215 There shaii be reservations in admission for students from the weaker sections. The
^election will however be based on merit and on achieving the required standard At no point
will tliere be <iny icduotioii in standards or marking on other comidcrations. For ensuring
equitable opportunity, the state govemment/coiieges win provide opponunitics lor coacnmg and
instruction to bring on par ant lagging students
1216 The Indian iNursnig Council wiii also be sirengdiened and ntide more accountable lor
ensuring better standards and quality' of teaching Tnfact nursing instniction is in most
kistitutions, corsidered to be very poor. Colleges of'Nursing will also be required to introduce
specialisation and dipiontis in midwifay, critical caie etc. Possession 01 such dipioiius ;
specialisation shall be the basis for nurses to work in certain departments and proirntions.
12.17 With die uiciease 111 die nuiiba of vwiikn gcuiiig education UpiO liigii schools, etc. die
minimum requirement of educational qualifications tor nurse midwives working m PHC’s
/subcentres should be revised.
FAKl VI
Health of Vulnerable Groups Women, Elderly and the Disabled Women;
1 > 1 The social and cultural erryironmmt is a major def^rminpot on womens’ health The low
social status, low levels of illiteracy and lack of equal opportunity arc responsible for infkicnciqg
die health statu s of women, in large pans of the country, the development process of last five
decades h*rF bypassed women though they' constitute 50% ofthe peculation
(BOX)
Tnc absaj^c of a hoiistiu uppioach to health and health caic ioi wohkii aiea guls
ba=ed on women’s right to the enjoyment of the higher attainable standard of
physical and nfcntalhealth tliioughulu the life cycle lias coiisUumcd piogjiess .... Tlie
predominant focus of health care systems on treating illness rather than maintaining
uptuiul health also picvans a holistic approach..... lack, of access to clean waul,
adequate nutrition, safe sanitation ofgender specific health research
The overall neglect of vvomen’s health is partly, on account of non availability' of disaggregated
data available on the morbidity or access to sei vices. Tnu e is reason to believe iiiat tliere is
stf>stantial under-reporting of data Besides, a woman’s health ha«; hitherto, been seen- in the
context of ha repiodijutivc functions, wiuuh too attained atuiitiun due to its 1114)01 tunce iui
population control Because of this overall neglect, the statiF of health of women continues to be
low, inhibiting and coits'uaining them from realisiiig ilteir full putaitial and their active serial
participation
Available data suggests a high level of morbidity and mortality' among women and girls on
accuuiii of pool sexual aiid iqjioductivc iicakh and inadequate nutrition, n diking ilieni specially
vulnerable to other endemic, infectious and communicable diseases and illnesses, such as malaria
IB, sexually tiaiiMliiued ue>cuscb, iijaiiai hcalul, liftstyle dhcasts, stxli
cctviCal cunca,
osteeprosis etc Maternal mortality and morbidity levels are unacceptfhly high among the
socially and etunuiuically disadvantaged sections, being double to those pievailing aiiKMig die
better off sections. Despite that investment in essential maternal and obstetric care has been
ddicialu
Similarly,daspite die csddcuvv oxpiogrossivc legislation, women continue to bo victirm of sexual
abuse and violence, constraining them from living productive lives
Since the root.caiFe of womens ’sense of‘deprivation and marginalisation is the low social status
accorded, public policy in India has been focussed on k>nriilatirg strategics aimed at the
empowennent of women and restoration of gender balance that will enable them to actively
participate in die development of die country widi dignity and social equality.
Finally, die rapid vfiaiges in niivioccvnoiriiv policies towards globalization and privatisation aie
of snecial significance to women as such forces tend to escalate the commodification of the
vVOiijeUtt UixM tliOu vtuuiun uipOvUhMuiiuii dUCcO CXploitaflVC Woriv COijditiOiiS ciiki pOOi" SvOial
security With a view to ensure womens’ access to health and health care services the National
Health Policy will oeck toi
-
FoiiijuLiv a vonprJiaioivohcaldipolky on Wonka’s Ikaltli,
f Establish, a Ilcaltli ?wcuicguiiUil and’, kiformation System that would cVialysc disaggregated
information on levels of morbidity among women, barriers to access health services,
occupational hazards that need attention etc.
’ Contcsd-ualizc women’s hcauli within die overall social and economic aiviromxnl
Accordingly in designing the initiatives on health, other aspects of errpowemient will be
included - uconoiiiic, cduccitiOix, ivgcil litcracy cind access to infbrnKition services.
* AppiCpriatc nkuburcts will bo taken to provide information and education on sexual health
within the framew’ork of the fami kT and the central itv of the woman to that institution.
• Develop ajpropnate strategies to ensure regular access to essential obstetric care and
rqpi-cductivc; health suvicoo, such <&> ru^ervirg one of die posts in die CIIC lor a woman
gynecologist development of midwifery, establishing women’s health center for every
^-■'O,vXXy p^piilaLiOil, WlKlOvC* uiCiO fas axicli a i iiod full etc. Such Womui Cunlwo would
nrovide the women the required confidentiality and privacy In these centers counseling
civiViCCts Will be iikKiC UvciilabiC, tuvij£^Wiili ciil tho SCTVivCo uicii cii O Women opCC'iliC.
-
rVCCOivi piiOiity cu-i-Ctitivxx tO mv jjj'vv CiitiOii ciiid Lcirly dctOCtiOil ofbiCoal, CCT ViCal oTid OVaTlcui
cancer and osteoporosis and sexually transmitted infections including HIV/AIDS.
• Ensure and develop policies tor gerider mainstreaming ot female health workers so that tiiw
can work in d^iily and provided security while at work
•
lake special care to ensure tnat ail health services ana providers conform to ethical
professional apd gender sensitive standards in the delivery of women’s health sendees and
ostoblhh aloiigddc, appr^riato rcgjulatoiy and aiforccmart. mcclianiims.
r
hr view of tlio special vuhaability of women to HFAAIDS due to ignorance and conseituoit
victimization in thetamilv. theneht to prior mtonnation on the partner’s health status will be
ensured. Likewise nitasurcs will bo put in place to -a^UiO tliat women suffo-ipg froin
HIV/AIQS or sexuallv transmitted infections are not discriminated against and can access
services freely and without stigpiatization
• Fomxilate special policies to provide easy access within reasonable access to psycliiatric aiid
counseling services. Psychological disorders and mental heaitli will be given high pnontv and
adequate budgets eunnarkod.
Elderly
Care
dJeily people
x**<.- u/jji <’ v vuki*i<? it* v^K’XK'xiij ciixvt xxkA.*xdx StutUS llti tC x Colixiva.* ixx dxC vi ccmvix
i« liugO gi <’i*p of
eider tv pecole above 60 vears. It is estimated that m 2(X)1. 6.7% of the Indian population shall
bv^xOiig to uii.j vcikgOiy.
xiiw xxUixa.>v« Will SWOxl to 0.v Ujr Axl6.
todav we have more than 67 million elder tv people
dcgkixCi cii-xi
pxxj .jx\.flogxvc*x p>x wiUxx.'.
juii cObOxcito xi'Uxxbvlo, OvCix
This groin will have age-related
x’•v.'-tibk cuxiCxig thcSO tiiiO UxScEiik-j
vx
VxSxOxi,
xxCiu xxj^p
iocorrotion. and ailments pertaining to cardiovascular and nervous systems. ( Gradual dilution of
joint fci.iily vonccpt a*;d wrakcmig of intcrgaieration links liavo placed additkuia! pressure on
the elderlv with significant decline m quahtv of care and emotional support tor them withm their
own families.
Overall inpiovuikiiio in die licalih of individual Jiall also pionoto lical&y agcii^g. EfToit,
should be made to nronde counseling to elderlv nettle to make them mentallv readv tor
accq^ting tlic old ago aix! to utilize their knowledge and cKpcriaicc in various ci* £c»s for *1ic
benetit ot the connunitv. Various echelons oi health care delrverv svstem shall be geared tp to
provide ger iatric care both in rural and urban arcin. Rdiabilitation of senior citizens will roceivo
special attention and concerted efforts made towards improving the aualih7 of their lite.
Diasahied
Persons suttenne from anv form of disability coratitute our highest consideration and support
TheAIfiiistiy of Huilth will take action to ensure that:
- A proportion of furds available under research will be oanixubod for areas rcVoant. to tike
cure, treatment and rehabilitation of the disabled:
•
All institutions will nro^de tor separate amansements tor the disabled to get access to care
without diSicuky;
r
-
Closely cooidiiiatc with the Ekpartimit of Social Justice and Ehpowunicnt in die
implementation of the disabled.
PARTW
Health Financing and Resource Mobilization
13.1 In India health is financed by tw major sources - taxes and households. It is estimated
that 75% of the total spent on healthcare is fromprhatc households while the rcmaiaiiig is from
government budget. This has raised serious questions of inequity’, as it is birther seen that the
poor spend disproportionately morc Ilian the rich It will therefore be die endeavor to increase die
proportion of government finding to 50^o with private and social insurance making up the rest
Health Insurance:
13 2 Advances in medical science and technology have improved early diagnosis, enabling early
cure, resulting in an overall inprovcincnt in die quality of life and reduction in human outfaii^.
These developments have also led to the institutionalization of care resulting in an exponential
increase in the cost, mukiiig it impossible to follow die dictum of non duiial of care to anyone on
grounds of inability to pay. With increasing evidence of the devastating inpact of one episode of
hospilalhalion in a middle class family and the incrcasipg level of indebtedness amorg the poor
on grounds ofborrowings for health, there is growing recognition of the need for providing some
form of iiisurancc and safety nets. Besides, healdi insurance is a powerful aiginc to spur quality
care and accountability among the medical practitioners while protecting the patient from
catastrophic consequences. IBwcva, in view of the potential of widening inequity due to die
inability ofthepoortobuy insurance a multi pronged strategy is envisaged which will consist of
efforts to.
• Expand, sUaigdicn, improve and sustain the delivery of health care services at all levels in die
public sector, so as to ensure to the extent possible that the poor are not denied care for want
of ability to pay.
Establish systans of social insurajicc to cover cs^paditures on hospital CcuO for 11 io poor Hi
cases vdiere government is unable to provide the service:
• Making insurance a mandatory requirement by those having a family income above Rs
13,<AX/ pvi xljL’iuli cuivi uiOSv vrv’i'ruiiix u’iv OT^culiZod oCCtOf,
* ELalablioh by law, alkaldi Liau a. ivv; Regulatory Authority to regulate and n unitor con panics
offering health insurance This body will be autonomous and the Regulator will have
constitutional immunity to protect him from intuforcncc or pressures. This body will also
have powers of adjudication and redress of complaints against health providers or institutions.
Tlio entire uspGiidituro to bo met by diis body will be borne by die Insurance companies. Thh
body will also be required to piblish and make available to the public and the legislature
t
infbnrntion regardins? the premiums charged die services provided die number of claims
fdcd, disposed OxTand div iidkifo of adjudication Uc.
r
n. liiiiiiiijxuii jjvi vvaiiogv vi uiv pi vtiliLuii wllvvliOiib Will bv xbi Capital iiiv vouiKiu. iii diC livaltli
sector - with both theprivate as well as public hospitals eligib le for such financing.
• For the purpose of enabling autonormus puli he sector hospitals eligible to offer insurance
products, appropr iate arr^idrmils to die Insurance Dill will be inkoduccd.
• To ensure equity, guidelines will be formulated to ensure diet no insured person is permitted
to avail uf ijcc Oi SlbsidiZed caie iil public liOSpiiars.
Expoi t uf Sei vivrs - Oiii1 Coiiipai^iive Advantage
14.1 The hcakh indusUy <*,uounis for almost uuee trillion dollais of trade, with the developed
market economies accounting for 80% of it. India’s share is totally disprenortionate to the
advantages li Cuiiiiiands -aluglily aisailcd xifcUipuWcx aiid luWCkwis.
Li order to increase our share in die global health nurket. govemmuit will pronwte and
encourage establishment of health tourism institutions of cxceiience oricring patient care or
training in medical and allied areas will be identified and a percentage of their capacity
etainadced for clientele ;villij^ to pey in dollars. Pat of aiming:; earned in foreig; excliaige will
be tamiirked for expanding similar facilities and ipgradation of quality so lhat overtime, there
will be an expansion of facilities forrneetw? the growing Hemal demand and also improvement
in die quality of training ohich will increase arployability abroad. Gh*m dur conporativc
advuuujgc, csiaDiisiiniuiL of facuiiics and naming institutions abioad will also be ax;ouiaged, if
necess'rirv bv amending the MCI Act
A RESPONSE TO THE REPORT ON INDIAN HEALTH SYSTEMS ISSUES
AND DIRECTIONS
by the Community Health Cell, Bangalore, 07/09/01.
Document : Changing the Indian Health System Current Issues and Future Directions
(ICRIER) - Rajiv Misra. Rachel Chatterjee and Sujatha Rao.
Comments : Dr. Ravi Narayan (Community Health Adviser) Dr. Thelma Narayan
(Coordinator), and Dr. C.M. Francis (Consultant), Community Health Cell,
Bangalore - 560 034. India.
These comments are based on a quick perusal of the above document and its appendices.
Due to time constraints a detailed review was not undertaken. A SWOT analysis
(Strengths, Weakness, Opportunities and Threats) approach has been used to review the
study.
The Document is an exhaustive compilation of data and perspectives within the short
time available to the group to study the situation of Health in India. It draws upon a
range of documents, reports and studies identified through an interactive participatory
exercise, tapping resources from a wide variety of sources. In that sense it is a good
document for debate and dialogue on policy imperatives. It is particularly significant
since its recent compilation and circulation for comment coincides with the recent release
of a National Health Policy - 2001 document that has been placed on the MOHFW
website for public debate.
Its Strengths are :
1. It endorses the key role of the state in safeguarding the citizens rights to health.
2. It underlines the abysmally poor investment in health with Indian health budgets
being among the lowest in the world, and suggests a wide range of options to enhance
this investment.
3. It correctly identifies an under performing public sector and a totally unregulated
private sector as the twin reasons for the poor quality of health care in the country.
4. It emphasises the need for revamping and making more efficient, the primary health
care system in the country apart from enhancing and strengthening public health
components and resources.
5. It highlights the fiscal crisis which has led to sharp reductions in non-salary recurrent
expenditures that have caused further deterioration of quality.
1
6. It re-emphasises the Bhore committee principle that access to health care services
should depend on individual need not on ability to pay.
7. It highlights the importance and need to monitor regional disparities (inter and intra)
in health care and health outcomes so that strategies for equity can be better focussed.
8. It identifies compartmentalisation; inadequate planning; insensitivity to community
needs; inadequate attention to health education and public disclosure; lack of reliable
epidemiological data; as among the systemic and structural weaknesses of the public
health care system and makes some suggestions to address these issues.
9. It highlights the top down approach with negligible community participation as the
foremost problem and suggests greater decentralization with capacity building of
local bodies and communities and their active mobilization and partnership.
10. It correctly identifies that private health sector providers are inadequately involved in
national health goals because of inappropriate and unethical treatment practices; over
provision of services; exorbitant costs; poor distribution and rise of unqualified illegal
practitioners; and suggests mechanisms for their balanced regulation and greater
involvement.
11. It identifies the gross inadequacy in the development of public health capabilities in
the system, as well as the lack of expertise in health economics, health finance, and
epidemiology and suggest steps to enhance these aspects.
12. It finally suggests that the reform approach must include a ' quantum jump in public
investment'; strong political will; strong peoples movement cutting across party
affiliations; vigorous informed debates in parliament, state legislatures, media and
public forums; and strong focus and commitment to primary health care, public
health, and action towards a more ' synthesized national system.'
Its Weaknesses are:
Like many recent documents in the 1990s it suffers from the following key weaknesses:
1. It does not contextualise health policy to the larger macro-economic issues and
directions of the new economic policies in the country, namely liberalisation,
privatisation, globalisation (LPG) These are known now to have made a negative
impact on the life and health of the poor and marginalised by decreasing food and
nutrition security; increasing rural indebtedness; increasing health care costs and
expenses; devaluing public health and primary health care under government
auspices; increasing exploitation by private health care; increasing environmental
degradation and increasing unemployment. It therefore fails to address these critical
issues in the recommendations.
2
2. It does not contextualise health policy evolution in the country to the global political
economy of health, in which international regulations like WTO, TRIPS, GATT,
patent laws, and global financial institutions; have an impact on aid and trade; and
have effects such as decreasing access and options for the marginalised and low
income groups in the country, thus worsening the health burdens of the poor.
3. While mentioning under - nutrition and malnutrition in passing under MCH and
communicable diseases, it ignores the poor nutritional status of people and the
worsening situation especially for children and the very young; and the urgent need to
strengthen food / nutrition security as a high priority item by itself, and not as an
adjunct to improving CDC and MCH goals.
4. It continues to emphasise women's health in its maternal and child bearing context
(reproductive health) without placing it squarely within the larger context of women's
low social status and subsequent related issues such as female feticide, violence
against women, gender bias; and the urgent need for women's empowerment and a
gender perspective in all health endeavours.
5. While emphasising the resurgence of communicable diseases it continues to locate
the response in a bio-medical context, using the disputed DALY concept for
measurement and focussing on techno managerial inputs and components of action.
Therefore it accepts and highlights top down selective strategies such as DOTs in TB
without recognising the socio-epidemiological -cultural-economic-political factors
that maintain TB in the community. In Malaria it does emphasise the links to
development strategies. Its research recommendations also fail to highlight the need
for active social / economic policy research and the active involvement of the
behavioral sciences in the evolution of community oriented and community based
strategies.
6. While highlighting the extraordinary social mobilization in polio eradication for
instance, it fails to recognize the now well evident social cost of a top down selective
primary health care strategy, that has adversely affected the other routine
immunization strategies, raising both the ethical dimension; the social cost; and the
relevance of the selective 'magic bullet' market economic strategies over more
comprehensive strategies.
7. It talks about restructuring the role of the MOHFW and mentions its stewardship,
guideline setting and regulatory roles. All these are important and necessary, but by
suggesting 'contracting out'; user fees and other market mechanisms without
highlighting how these new private partners, will practice, promote and strengthen the
governments constitutional mandates to equity and fundamental protection of citizens
from illness and premature mortality; a mandate which the private sector and even
some of the NGOs have failed to recognise so far. It offers recommendations that are
not evidence based. In fact all the available evidence points to the contrary.
3
8. It totally neglects human resource development - there is no chapter and no
recommendation on reorientation of basic training of the health team; continuing
education and capacity building, motivation and incentives. This is a particularly
significant lapse when the country is witnessing a phenomenal commercialisation and
mushrooming of private educational effort to produce medical teams for a growing
medical market.
9. It does not adequately relate its situation analysis to the context of the growing market
economy of health care, in the country which in the 1990s has reached epidemic
proportions, symbolised by commercialisation of health care; increase in costs;
kickbacks and fee splitting; over investigation; irrational and unethical treatment
practices; unethical inducements by the medical industry for health care service
providers and so on. Even the ICMR / ICSSR Health for all report in 1981 had
warned of the " need for eternal vigilance to ensure that the Doctor - Drug producer
axis does not develop a "vested interest in the abundance of ill health!"
Finally it fails to identify important cross cutting issues which affect the equity, quality
and integrity of health care, These are reflective not just of the health sector but are issues
that affect all other sectors as well, and araise from our socio-cultural economic - political
framework of governance.
The Kamatka Task Force on Health and Family Welfare in its final report, released in
April 2001 has identified twelve such factors. These are:
Corruption and political interference.
Overall neglect of public health.
Market economic distortions of primary health care.
Lack of focus on equity.
Inadequate understanding of the implementation gap.
The decline in commitment to ethical values.
The overall neglect of human resource development.
The continuing cultural gap and insensitivity to our pluralistic culture including
medical culture.
i. Continuing governmental exclusion in development partnership.
j. Ignoring the political economy of health and development at micro and macro levels.
k. Neglect of research.
1. Growing apathy and cynicism in our health care system reflective of our national
ethics.
a.
b.
c.
d.
e.
f.
g.
h.
Opportunities
This document needs to be subject to wider public and professional debate, so that it
builds further on its strengths through consensus, and counters its weaknesses through
greater commitment to evidence gathering, moving away from adhoc analysis and
decision making, to a more researched, grounded and well thought framework.
4
Threats or Cautions
Since this document gets linked to a very high profile process such as Macro - economic
Commission on Health, there is need to ensure that it is seen primarily as a case study put
hurriedly together with inadequate multidisciplinary expertise (public health and
behavioral science perspectives are particularly weak), but relevant all the same for
debate but not for decision making. As the key author has put it in the preface itself this
report 'should help improve the understanding of health issues, generate awareness and
stimulate an informed debate'. Nothing more, nothing less. It should definitely not be
projected like WDR - 93 of the World Bank which was a similar document, but due to
high profile lobbying developed an aura and status of a decision makers manual, with
many of its recommendations later having to be modified by the authors themselves.
5
A Review Meeting on the Draft NHP-99 Document
An interactive participatory dialogue was held at KHSDP Office (Public Health Institute)
on the draft National Health Policy-1999 (Government of India-Ministry of Health and
Family Welfare). The meeting was facilitated by Community Health Cell (CHC)
Bangalore at the initiative of Dr H. Sudarshan, Chairperson of the Karnataka Task Force
in Health. The meeting brought together about 20 resource persons representing different
disciplines and sectors so that the policy document could be reviewed from various
angles. These disciplines included Public Health, Community Medicine, Clinical
Medicine, Demography and Statistics, Management, Nutrition, Social Sciences, Mental
Health, Research, Health Humanpower Development and so on (see list in Appendix I for
further details).
All the participants had received a copy of the draft policy document and had come very
well prepared so the meeting brought together a wealth of ideas, perspectives and
suggestions. We hope the policy formulators will take these suggestions in the spirit of
solidarity in which they are shared.
The minutes are compiled into the following sections:
A)
B)
C)
The comments on the overall framework of the document.
Additions, lacunae or omissions in the document including suggestions for re
wording, re-orienting or re-integrating parts of the document. This is presented in
the chronology of sub-headings in the draft document and the relevant paragraph
number pertaining to draft policy document.
Comparison was also attempted between NHP-83 and draft NHP-99 and this is
enclosed as an appendix.
A)
General comments:
i)
The document is not well integrated. It is not clear whether it is a policy
document, a programme document, a plan of action or all put together.
The language is very variable, quite uninspiring and varying in quality. It seems
to be many different contributions put together, unedited.
Editing needs to be done, effectively keeping the language crisp, brief, readable
and formatted in an attractive way, with headings and sub-headings that make
perusal interesting.
Some places the wording is apologetic and in some places there is far too much
detail for a policy document.
There is no sense of priority and all issues seem to be given same importance
even though magnitude, relevance, impact or need may be very different.
In many places the statements are ambiguous, not specific. There is need for
clarity and specifics.
ii)
iii)
iv)
v)
vi)
Cci333'd National Health Policy Review of Draft NHP-99 doc
Page 1 of 14
vii)
Considering this is only a draft document some of the above may be accepted as
part of an evolutionary process but a logical framework and professional
presentation is definitely required.
The document should have:
A Preamble—
(a)
A situation analysis —
(b)
(c)
(d)
(e)
(f)
B)
1.10
why NHP-2000.
The health situation.
The successes or failures of NHP-83 (including
where we are in the goals indicated at the end of
NHP-83 document) and why this is so.
The Vision/ Mission — Policy of Government in 1999-2000.
Then all the sub-sections in the present document — slightly integrated or
re-arranged.
The goals of the policy, the monitoring-evaluation policy and mechanism
by which the policy is renewed/reviewed through action and evidence.
The Health Policy document should be a comprehensive one, so that the
other policies related to health — be in population; drug; blood bank;
nutrition policy; health human power development; AIDS control; should
be integrated into it.
Some Concerns: (only key concerns shared in the meeting are included)
Decentralization;
In spite of increasing overall commitment (Item 1.10 of draft NHP-99) to
i)
develop models to show how Panchayati Raj institutions (PRI) can be
made responsible for rural health care institutions, there is a tendency to
promote District level single health problem focussed societies for TB,
AIDS etc. which contradicts this commitment . This distortion must be
reviewed urgently.
As a preparation for transfer of decentralized responsibilities to PRIs,
ii)
training of PRI members and leadership in assessing community health
needs and priorities must be done on a high priority basis.
2.1
Epidemiological Transition:
While epidemiological transition is taking place, it is taking place at different
levels in different classes and there is need to ensure that what affects the 10%
upper class of the population does not overshadow all the priority problems of the
remaining 90% of the population.
2.3
The proposed policy for local practitioners to be permitted to pay rent and
practice in PHCs, after OPD hours, is not a very sensible policy since it could lead
to all sorts of distortions and unethical practices. In areas where there is great
need, and the absence of government personnel, this could be experimented with
in the interim/ short term very cautiously.
Ccl333'<tNauoiui Health Policy Review of Draft NHP-99doc
Page 2 of 14
2.4
The need for establishing a senior focal point at the district level for health, family
welfare and women and child development schemes have been recognized. The
States would be encouraged to set up a district-based hierarchy for overseeing the
implementation/ of national programmes and public health functions. Persons
withr postgraduate qualifications and or training shall be posted for
administrative posts from district level and above.
2.5.1
The State Institute for Health and Family Welfare will be established and
developed as an apex training centre to promote public health, epidemiology and
health management skills at all levels.
3.
Environmental Health: is a very important issue and with increasing pollution
of air, water and soil,, due to indiscriminate and unplanned industrialization;
inadequate waste disposal and pollution control; inadequate monitoring and
control. The health hazards for urban population more specifically and the rural
population more generally, is increasing and needs to be tackled on a priority
basis.
3.4
Add local health traditions to list of traditional pillars.
3.6
Public Health:
Needs to be strongly re-emphasised and also accepted as the primary
responsibility of the government guaranteed constitutionally. Even if partnerships
are evolved with other sectors, the primary responsibility should be with the
government.
Also within public health policy, intersectoral approaches to tackle all the
determinants of health should be included and focus on just a few preventable
diseases with top down vertical programmes should be avoided. Horizontal
integration and intersectoral approach should be clearly emphasised.
3.9
Nutrition: should be a separate section and not a sub-section of Environmental
Health and Sanitation.
3.10
Important to ensure that the new focus on micronutrients should not distract or
distort the overall focus on malnutrition. The basic problem is food available in
the diet, not absence of zinc or iodine by themselves. This will ensure focus on
broader issues of Nutrition and food security including:
Public distribution system
a)
Availability of adequate cereals and pulses
b)
Importance of kitchen gardens
c)
3.12
The public distribution system and nutrition of people have a close intersectoral
link and this interphase should be mentioned and the focus not only on increased
'Cel333'd\Nalionai Health Policy Review of Draft NHP-99<ioc
Page 3 of 14
food security (as agricultural policy) but also access to adequate food - nutrition
security (as Health policy) should be clearly stated.
Role of School Health and Nutrition education programmes must be mentioned •
specifically.
Importance of nutrition in health needs greater emphasis in education/training of
all health personnel.
4.2
Tuberculosis: Since RNTCP will take a decade to spread over the whole
country, there is need to mention NTP and its strengthening, not just RNTCP.
4.3
Leprosy: There is need to continue to stress survey education and training (SET)
and to detect and treat effectively without letting the success of MDT overshadow
the reality.
4.4
AIDS Control Policy:
l
Home based care and strengthening skills of careers at this level must be an
important focus and component.
The exceptions that have been allowed in the Blood Bank policy for the army
medical units may be considered for certified/registered units in rural/tribal and
remote areas ro enhance access and availability of blood for the poor.
Draft National Blood Banking Policy (In Summary)
4.5
The Draft blood banking policy while setting quality standards must reconsider
peripheral health centres and field situations where collection can still be done, to
help access to blood for poorer and more marginalised sections of the community.
4.6
Malaria
4.6
Vector Borne Diseases:
Vector borne diseases like Malaria, Filaria and Dengue are rampant all over the
country. In addition, Japanese Encephalitis, KFD and Kalazar are also prevalent
in specific pockets in the country. These diseases cause high mortality, therefore
all of them should be notifiable and special bye-laws should be made applicable
to all these vector borne diseases.
Selective and location specific vector control is the right approach. Bioenvironmental control which is eco-friendly, sustainable, high cost effective
should be given top priority*for long term sustainable control strategies.
The involvement of the community in the prevention and control of vector borne
diseases will be given the strongest emphasis with the aim of eliminating
mosquito breeding through active health education and community participation.
Ccl333'd'<NauonaJ Health Policy'Review of Draft NHP-99 doc
Page 4 of 14
4.7.1
Malaria (as in 4.6 in draft document)
4.8.2
Filariasis (as in 4.7 in draft document)
4.9.3
Dengue (as in 4.8 in draft document)
4.10
Kalazar. This is restricted mostly to parts of Bihar. More intensive action
research and efforts to provide curative, preventive and promotive care to the
affected people must be made.
4.11
KFD is only restricted to a small pocket in Karnataka. Proper efforts should be
made to eliminate this disease from this pocket through adequate and relevant
public health measures.
4.12
Japanese encephalitis must be mentioned.
4.13
There is adequate information on the vectors and their biology in the country.
Posts of medical entomologists will be created at district levels. These posts will
be at the senior scientist level. Recruitment of such posts will be made strictly on
merit.
5.4
Backlog of cases with cataract related blindness may still need a camp approach
so setting quality standards for camps may be better than phasing out.
5.7-5.9 Persons with Disabilities;
All aspects of the Disabilities Act need to be highlighted , not only prevention.
National disability rehabilitation plan needs to be mentioned.
School health as a forum to prioritise and address problems of differently abled
children.
GBR should be promoted in the curriculum of all health personnel at all levels.
(When the health policy speaks about involving any other partner from NGO
sector, private sector, corporate sector, GPs, traditional medicine sector, folk
sector etc. the word "used" should be changed to "involved" or "enhance
collaboration with" in the true sense of partnership).
5.8
In disability section -- medical aspects should also be highlighted and the need for
enhancing skills in physiotherapy and occupational therapy in the health team in
general apart from enhancing training for allied health professionals, and
therapists in particular, should be emphasised.
6.
Drug Policy:
Cel333'zf Natioiul Health Policy Kcnew of Draft NHP-99 doc
Page 5 of 14
a)
The goal and emphasis on self reliance in drugs and vaccine production
should be emphasised and drug policy should promote this proactively.
b)
The indigenous production of testing kits for Hepatitis 'C and HIV/AIDS
will be encouraged. There should be increased emphasis on rational
prescription practices, and CME for practitioners on Rational Drug use
should be encouraged in association with professional associations and
medical colleges.
6.9
-------- Likewise enhancing the production of purified rabies immunoglobulin
and their wider use will be permitted.
8.
Trauma and Emergency Services:
While the focus on trauma /accident is an important one - there is need to
include
emergency service focus on two other important and common
emergencies:
Obstetrical emergencies
a)
Snake bites. Steps to increases effective response to these must be taken.
b)
8.3
(reworded)
(i)
Disaster preparedness - Response and rehabilitation plans should be drawn up at
the National and State levels.
Large government and private hospitals should have contingency plans for
management of mass casualties.
Adequate resources should be made available for, (i) and (ii) including through
involvement of private and NGO hospitals and who volunteers to treat victims of
accidents and disasters.
Training in disaster preparedness for doctors and other health professionals should
be organized regularly.
(ii)
(iii)
(iv)
10.1-10.3
Health of Women and
10.4-10.8
Health of Children
Since IMR/MMR are still unacceptably high, these programmes should be
accorded top priority, not just as special groups but as key focus running through
the entire policy.
10.4
Health care of the children:
Cel33Td National Health Policy Review of Draft NHP-99doc
Page 6 of 14
The focus on 0-2 years must be emphasised and given high priority. They are the
most vulnerable and presently inadequately reached.
10.9
Elderly persons:
-------- Developing geriatric medicine as a distinct specialty with training
programmes as well as promoting care of the Aged Programmes will receive
priority as an investment for the future.
10.10-10.15
Mental Health:
Should be brought under non-communicable section.
There is need to set accept minimum standards for public/private health centres
and institutions e.g. standards for mental hospitals have been accepted by central
mental health authorities.
10.12 The pilot community mental health programme under implementation should be
expanded after adequate evaluation and assessment.
Tobacco/ Alcohol:
Should be brought under or after Mental Health, as a separate section, but also to
highlight the important risks to mental health as addictions.
10.16 Dental Health:
Training of paramedical dental worker should be mentioned. Also there is need
for a community based and oriented dental service extension programme.
HMIS
11.7
Self recording blood pressure instruments are incongruous in a section on HMIS,
apart from probably being a response to some medical technology lobby. Are
they really needed? Why self recording?
Hand held electronic data^entry machine need to be clarified. For what purpose?
Is this another lobby? Both technologies are not high priority.
Private sector regulation;
12.6
---------The Medical. Nursing and Dental Councils will be enjoined to play a more
effective role in checking the unethical aspects of private practice including over
pricing and profiteering at the cost of the ignorant consumers. The pricing policy
of each centre/ institution could be exhibited or easily accessible to the user.
12.9
Social responsibility of industry:
Cel33^National Health Policy Review of Draft NHP-99doc
Page 7 of 14
While promoting social responsibility in private and corporate sector is an
important step forward, increased emphasis on quality control accountability and
transparency in government public sector must also be emphasised.
12.9
---- This sector should also be encouraged to be more actively involved in public
health programmes especially all the National Health Programmes.
13.
Medical Education:
Medical education must be need based and community oriented. So policy of
growth and development must emphasise this.
13.4.1 Schemes to encourage medical graduates to go to rural areas
government hospitals and or rural practice will be evolved.
to work in
13.11 Humanpower Resource Development:
The focus on NHP has been on Doctors and Nurses and some allied heath
professionals. No mention of male and female health workers, traditional birth
attendants, anganwadi workers, community based health workers, school
teachers etc. who form the main basis of primary health care. This should be
given a separate section.
13.11.1There will be a separate body to look into manpower utilization in all health
departments. All vacancies should be filled up to strengthen the health
department.
13.11.1 All medical teachers shall be full time and non-practicing and will be encouraged
to undertake research work. They shall be given appropriate compensatory non
practicing allowances.
13.12.1 Admissions to all courses in medicine and health sciences will be on merit and
through common entrance examinations.
14.
Medical Education:
Some additional policy recommendations:
a)
Teacher training should be made compulsory for all medical college teachers.
There will be one institute in every state, that shall be strengthened to be an
academic staff college, for training teachers for health professional institutions.
All staff posted for training should be supported on official duty basis.
CcBJTd Nauoiul Haith Policy Review of Draft NHP-99 doc
Page 8 of 14
b)
16.
Reform of the existing examination system: is a need of the hour especially
since it has been subject to all types of manipulation and corruption, The
measures to establish quality control in medical education should include:
For MDBS, a grading system (like NCERT has recently introduced for Std
(i)
X at school level) may be introduced. This will include periodic
assessment and final certification with a grade instead of markings.
More
weightage for internal, concurrent assessment and less weightage for
(ii)
external, terminal, passing out examinations.
(iii)
Stricter control over manipulation and unethical practices in the system. If
necessary by open viva voce/clinical evaluation.
Medical Research:
There is need to state that Ethical Guidelines for Medical Research recently
formulated by the ICMR under the chairmanship of Justice Venkatachalaiah,
Chairman, National Human Rights Commission should be strictly adhered to by
all researchers in the country. There is also need to constantly monitor this and
revise and update the guidelines from time to time.
.
Epidemiological Research units should be promoted in all medical colleges.
Research as a skill in the education training of all health personnel must be
emphasised. This must emphasise critical reflection on existing practice, existing
experience, existing data as a method of quality improvement.
16.2
Externally aided projects:
There is need to critically assess the role/impact of externally aided projects
especially large loans and grants on public health and primary health care
programmes in the country. Are they enhancing effectivity, outreach, equity or
are they distorting the system?
Health Education:
This needs to be emphasised and mentioned under a separate section and also re
emphasised in every relevant section.
(To be added after the section on Policy on Indian Systems and Homeopathy)
18.5
Local Health Traditions:
Situation: The people's health culture includes widespread eco-system specific
and ethnic community specific "oral" health traditions. These traditions use over
\Cel333\f\Natjonal Health PolicyvR«rv>ew of Draft NHP-99 doc
Page 9 of 14
8000 species of plants for health care.' Local health traditions include herbal
healers, bone setters, traditional birth attendants, visha vaidyas, etc. and are
estimated to be over a million in the villages in India. There are also several
hundred million rural household traditions of home remedies and local
knowledge, related to food and nutrition.
Policy:
These oral health traditions need to be recognized and revitalized through
i)
suitably designed programmes as a measure for strengthening public
health education and encouraging self-reliance in primary health care in
rural India.
These biological resources and the intellectual property rights (IPR) of
ii)
local communities need to be protected from bio-piracy.
Cei333'd National Health Policy Review of Draft NHP-99 doc
Page 10 of 14
C)
A Comparative Analysis of NHP-83 and NHP-99 (Draft)
1.
Historical Context:
The NHP-83 was announced against the historical background of the Srivastava
Report (1974); the Alma Ata Declaration on Primary Health Care and Health for
All by 2000 AD, to which India was both a major contributor and an enthusiastic
signatory (1978); the ICSSR-ICMR Health for All Report (1981); and the
populist politics of the early 80's which led to the evolution of the 20-point
programme in which some health issues were key components.
On the other hand the Draft NHP-99 should be contextualised against the
background of the Structural Adjustment Programme of the 1990s leading to New
Economic policies favouring Liberalization, Privatization and Globalization; the
emergence of World Bank as an important funder of Health programmes; and the
gradual shift from health budget increases to increased loans for vertical disease
control programmes. All this situated in the context of the constitutional
amendment for greater de-centralization and Panchayatraj, and the coalition
politics of the 1990s, balancing different interest groups and lobbies.
2.
Successes Identified:
The successes identified by NHP-83 were eradication of smallpox and plague; the
reduction in the problem of Malaria and Cholera; the reduction in Mortality rates
(27.4 to 14.8); the increase in life expectancy (32.7 to 52); the massive increase
in network in health care; the increase in the stock of trained health humanpower;
and the increased indigenous capacity in production of drugs, vaccines and
equipment as a sign of self-reliance.
The NHP-99 highlights the successes as the reduction of birth rates, death rates
and IMR; the substantial increase in immunization rates - BCG-96%, TT-80%,
DPT-90%, Measles-88%; the pulse-polio programme; the reduction in leprosy;
the eradication of guinea worm infection; and some success in the cataract
blindness programme.
3.
n
The concerns:
The concerns shared in NHP-83 included the continuing population growth; the
unacceptably high mortality rates for women and children; the high IMR; the
p continuing malnutrition problem; the continuing high rates of leprosy, TB and
blindness; the problem of access to water supply (only 31% have access); the
problem of access to sanitation (only 0.5% have access); the high rates of
diarrhoeal diseases; and the poor environmental sanitation.
The most significant feature of the NHP-83 was the powerful historical analysis
which blamed the curative hospital based models of response which neglected
Primary Health Care; increased; and continued the cultural gap in the
CeiaJTdXNaiional Healih PolicyRme. of Draft NHP-99<ioc
Page 11 of 14
training of health humanpower. The NHP-83 also acknowledged poverty and
ignorance as the main cause of continuing ill health.
The NHP-99 on the other hand is concerned about the re-emergence of Plague,
Dengue and Malaria; the emergence of AIDS and Hepatitis; the continuing
nutritional deficiencies; the increase in non-communicable diseases like cancer,
diabetes and CVS disorders; and the problem of contaminated water and
environmental pollution.
It does however mention ill planned urbanization; persistent gaps in manpower;
sub-optimal referral systems; inter-state differences; lack of diagnostic and
treatment manpower; and such techno-managerial factors.
It mentions in passing the increase in environmental and societal problems but
concedes that technical advances have been denied to most of the population due
to lack of resource; lack of awareness; lack of services; and lack of a rights'
perspective.
4.
Challenges/ Approaches:
NHP-83 emphasizes the universal provision of Primary Health Care; the need to
overhaul approaches to training and education; the need to reorganize health
services infrastructure; the relationship of health to development, including
agriculture, food production, rural development, education and social welfare,
housing and water supply and sanitation, and the need for a Drug/Pharmaceutical
policy.
The NHP-99 on the other hand emphasizes the need to reduce inter-state
disparities and differentials; the devolution of authority to Panchayatraj
(decentralization — the need to make primary health services more responsive to
community needs); the need to restructure the existing systems using cost,
participation and result orientation as key factors; and the need to evolve
appropriate policies within the constraints of poverty and illiteracy.
5.
The New Areas:
The NHP-83 particularly highlighted the health issues that had been included in
the 20-point programme.
vis NHP-99 on the other hand has emphasized the partnerships with the private
sector; other systems of medicine; the role of media, civil society and judiciary;
the need to look critically at health finances and insurance; the aged; the need for
health impact assessment of large development programmes; and also mentions
the need to study the impact of economic policies on health.
Overall the NHP-99 draft policy represents a major shift from NHP-83 in some
significant ways:
Ccl333'<fNatiorul Health Policy'Review of Draft NHP-99 doc
Page 12 of 14
i)
ii)
iii)
iv)
V)
The increasing verticalisation of health programmes.
A greater shift to techno-managerialism from earlier attempts to focus on a
more comprehensive socio-economic-political cultural problem analysis.
A change of focus from vulnerable groups to specific disease problems.
A greater adhocism in plan formulation responding to market economy,
lobbies and funding agency driven agendas rather than a more
comprehensive evidence based National planning.
A reduction in overall emphasis on the determinants of health and public
health approaches to programme planning. However, there are some
significant positive trends in comparison to NHP-83 particularly.
The Rights perspective in Health is emphasized.
(a)
The private sector is increasingly recognized in the policy context
(b)
with greater emphasis on its regulation and quality control.
The Indian Systems of Medicine are given more emphasis though
(c)
the policy is just evolving.
Source: Community Health Cell, Bangalore
367, 'Srinivasa Nilaya’
Jakkasandra I Main
I Block Koramangala
Bangalore 560 034
Tel: 080-5531518
Telefax:
080-5525372
Email:
sochara^vsnl.com
Date:
28 April, 2000
\Ccl333'<ftNauonai Health Policy Review of Draft NHP-99 doc
Page 13 of 14
Appendix I
Participants of the Dialogue on NHP-99 Draft Policy
Document on 15.3.2000 at KHSDP Office
(Some areas of interest/expertise shown in brackets)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Dr. C.M. Francis, Consultant, Community Health Cell and Member Karnataka Task Force in
Health. Chairperson. (Health Management, Ethics, Law).
Dr. D.K. Srinivasa, Medical Education Consultant, Rajiv Gandhi University of Health Sciences,
Karnataka. (Community Medicine, Health Humanpower Development.)
Dr. Ramesh Billimagga, President Elect, Indian Medical Association. Karnataka Chapter.
(Clinical Medicine, Oncology).
Dr. H. Sudarshan, Director VGKK, BR Hills and Chairperson, Karnataka Task Force in Health.
(Community Health, MCH, NGO, People's Empowerment).
Dr. Thelma Narayan, Coordinator, Community Health Cell, Bangalore and Member, Karnataka
Task Force in Health. (Epidemiology, Public Health Policy).
Dr. M.K. Sudarshan, Principal, Kempegowda Institute of Medical Sciences and Head of the
Department of Community Medicine. (Community Medicine, Communicable Diseases).
Dr. Mohan Isaac, Professor and Head of the Department of Psychiatry, National Institute of
Mental Health and Neuro Sciences, Bangalore. (Mental Health).
Dr. Latha Jagannathan, Director TTK Blood Bank, Bangalore and Member, Karnataka Task Force
in Health and CII Committee on Social Responsibility of Corporate Sector.
(MCH, NGOs, Private Sector).
Ms Padmasim Asuri, Retired Nutritionist and Regional Home Economist, Government of India.
and DANIDA Consultant, Women and Agriculture. (Nutnuon, Women's Health).
Dr. Ramesh Kanbargi, Demographer, Institute for Social and Economic Change, Bangalore.
(Demography & Population Policy, Decentralization).
Dr. S.K. Ghosh, Officer in Charge, .Malaria Research Centre (Indian Council of Medical Research)
Bangalore. (Research, Vector Borne Diseases)
Dr. Tiwan, Research Officer, Malaria Research Centre (ICMR) Bangalore.
(Vector Borne Diseases. Community Participation).
Dr. Nagabhushan, Professor of Department of Medicine, Government Medical College.
Bangalore. (Clinical Medicine, Ethics, Medical Education).
Dr. S. Pruthvish, Coordinator. Disability Unit, Action Aid, Bangalore.
(Community Medicine. CBR, Public Health).
Mr. As Mohamed. Asst. Professor. Statistics & Demography, Department of Community Health.
St John's Medical College, Bangalore. (Demography, Statistics, HMIS. Population Policyi.
Dr. Ravi Narayan, Community Health Advisor, Community Health Cell. Bangalore
(Public Health. Industrial Health, Medical Education).
Dr. James Parayil Joseph, Consultant Dermatology, STD/Leprology, Research .Associate.
Community Health Cell, Bangalore.
Mr. S.D. Rajendran, Research Assistant, Community Health Cell. Bangalore.
Mr. A. Prahlad. Training Assistant, Community Health Cell, Bangalore.
Mr. S.J. Chander. Medical Social Worker, Bangalore.
Sent comments but could not attend:
21.
22.
23.
Dr. R.L. Kapur, Consultant, Psychiatrist and Social Science Research. Community Health Cell.
Bangalore. (Community Mental Health, Social Sciences, Research).
Mr. Darshan Shankar. Director, Foundation for Revitalization of Local Health Traditions,
Bangalore. (Folk Medicine, Indian Systems of Medicine).
Dr. Pankaj Mehta, Professor & Head, Department of Community Medicine and Vice Dean,
Manipal Hospital, Bangalore. (Community Medicine, Public Health).
CeOJId National Health Policy Review of Draft NHP-99 doc
Page 14 of 14
Suggestions for the Draft National Health Policy from a
Consumer Group.
The quality of the food grains and other commodities supplied through the Public
Distribution System (PDS) needs to be improved, if nutrition is a key issue for
health.
The health policy should include provision relating to safety of patients
(consumers) - safe equipment's, safe blood and drugs and safe environment in
hospitals and nursing homes.
Recycling of used syringes, needles etc, has become a racket. The health policy
should provide effective control measures and severe punishments for violations.
The health policy has a provision on drug information including warnings and the
role of pharmacists in providing information to consumers. Independent drug
information centres are to be set up where consumers would be able to get full,
accurate and unbiased information about drugs.
Though the Government drug controllers issue notice of drugs banned,
consumers have no access to these documents. Besides, the list of banned drugs
are in generic names which is of no use to consumers. The health policy should
make efforts to give the brand names of drugs banned.
Prevention of food adulteration.
It is essential that this Act be amended to make it more consumer friendly. If the
National Food Council is established, as given in the health policy, it should involve
voluntary consumer organisations.
Other issues to be included in the policy
A charter of patients rights and responsibilities
A citizens charter for hospitals and nursing homes
Right to Information to patients
\Ccl333'4fNational Health Policy Suggestions for Draft National Health Policy fonn Consumer Group.doc
[pha-ncc],2001 Praft Health policy
SuDbjectt:
20011 UDiraffit Hleaillttlh poHfcy
Date Sat, 8 Sep 2001 17:26:31 +0530
FTOinms ’’DBaneijee” <nhpp@boLnet.in>
To: <aeabop@nb.nic.ln>
CC: ”pha-ncc’’ <pha-ncc@yahoogroups.coni
September 8 2001
AN IMMEDIATE/INTERIM RESPONSE TO THE DRAFT
NATIONAL HEALTH POLICY 2001
Debabar Banerji,
Professor Emeritus,
Jawaharlal Nehru University,
and
Convenor, Nucleus for Health Policies and Programmes
B-43, Panchsheel Enclave, New /delhi 110017.
Tel:649 0851 & 649 8538E-Mail:: nhpp@bol.net.in
1. As one who has been involved in health policy studies for over four
decades, I thought I must get together my experiences and ideas to offer my
comments on the Draft.
2. As the time limit for comments is woefully inadequate, I am responding
within 12 hours of receiving the draft. I have made an effort to keep my
effort ruthlessly brief - about one tenth of what I ought to write. I
certainly will not be comprehensive in this very brief presentation. I will
be glad to elaborate any points that may asked for.
3. MY MAIN COMMENT IS THAT A DOCUMENT THAT CLAIMS TO BE A POLICY INSTRUMENT
IS CONSPICUOUSLY WANTING IN FOLLOWING SOME OF THE BASIC TENETS OF THE WELL
RECOGNISED AREA OF POLICY STUDIES; IT SIMPLY "HANGS IN THE THIN AIR" , AS IT
WERE, WITHOUT A PAST, FUTURE OR EVEN A SEMBLANCE OF UNDERSTANDING OF THE
FACTORS WHICH HAD AND WHICH WILL INFLUENCE POLICY FORMULATION AND ITS
IMPLEMENTATION. IT IS AHISTORICAL, APOLITICAL ATHEORETICAL AND IT LACKS IN
BASIC ACADEMIC RIGOUR REQUIRED FOR THE TASK.
I. THE DRAFT
4. Before I start with a critique, I will express my admiration for the
excel 1 ent way it has been written, in sharp contrast with the confused not
very coherent or cogent way the the 19982/83 Policy was written and
presented. I admire the 55-35-15 per cent formula for distribution of
resources for primary, secondary and tertiary levels. I particularly note
the mention of the phrase "scientifically optimum" advocacy for programme
formulation. As the subsequent analysis will show? this phrase~^7as~prubably
used in a state of absentmindedness!
5. Even if we ignore the fact that the Draft "hangs in thin air", it is
bristling with infirmities. Only a few instance will be sufficient to expose
the infirmities:
a. It is deafeningly silent on the critical question of health
administration. - from the very top to the bottom. The Draft has not
confronted the critical issue of vivisection of the Ministry of Health into
the very endowed Department of Family Planning/Welfare and the
neglected Department of Health. The Family Planning Department has been
acting as a "as a ragincpbuTT+in the China shop" of the health services of
the country for more than three decades and a half! It has not only
devastated
the health services of the country, but it has miserably failed to attain
its objectives, as seen by decadal increases in the population (from 351m in
1951 to 1006m in 2001) which are horrendously correlated with astronomical
1 of 4
9/10/01 12; 10
pha-nccj.2001 Draft Health policy
growth in the allocations - Rs6.5m in_the_the First. Plan to Rs65-r 000—in—the
EigTitir~PTan7 ’GREATER'THE ALLOCATION, GREATER IS THE RISE IN POPULATION
GROWTH - AND GREATER IS THE DAMAGE TO THE HEALTH SERVICES! Those
responsible were not held accountable for this disaster. Surely the authors
of the 2001 Policy
are aware that in the state of Uttar Pradesh where there are five positions
of
one each for
‘Secretaries in the Department of Health and Family Welfare
family welfare' Health, medical care and medical education, with an
overaching Principal Secretary to oversee their work!
b. After the abolition of the cadre of the Indian Medical Service, there
has been a steep decline in the quality of the leadership
from medical personnel. Critical public health posts at the Union and State
levels are occupied by persons who lack basic competence for the jobs. The
Draft overlooks the blatant anomalies in the structure of the Central Health
Service
There is a blatant contradiction in the draft concerning the Vertical
Programmes.
After pointing out their incongruity and extremely poor cost-effectiveness,
the Draft wants these to go on till the diseases are controlled. This is a
prescription for their "eternal” continuation, if we look at the programmes
like malaria and tuberculosis - and, of course, Family Planning.
d. The approach to medical education is patently unacademic. Has the UGC
increased the quality*of higher education of India? What can we expect from
the Medical Education Commission, which is being lobbied for at least four
decades? What is our experience with medical universities? What about the
politics driven private medical colleges? Do the authors know that a recent
survey of medical colleges (NATIONAL MEDICAL JOURNAL OF INDIA) showed that
about 90 per cent of them do not conform to most elementary requirements of
a teaching institution?’
e. The authors do not seem to have learnt from the original sin committed
in West Bengal in the seventies to train Health Assistants; now they are all
agitating for a condensed course get the MBBS degree!
I would end this here. The list can go on and on for quite some time
II
TOTAL NEGLECT OF BASIC POSTULATES OF POLICY STUDIES
6. The authors of the Draft do not seen to have understood that health
policy formulation is a (i) socio-cultural, (ii) political, (iii) economic,
(iv) technological and (v) organisational
and managerial process, with profound (vi) epidemiological and (vii)
sociological dimensions. It is not a 11 secretarial11 process. I have discussed
these issues in a paper with title: A SIMPLISTIC APPROACH TO HEALTH POLICY
ANALYSIS: THE WORLD BANK TEAM ON THE INDIAN HEALTH SECTOR,which I had
insisted on publishing in our own ECONOMIC AND POLITICAL WEEKLY (June 12
1J293, pp.1207-1210) . It was also reprinted in the INTERNATIONAL JOURNAL OF
HEALTH
SERVICES (vol.24, no.1,1994). Incidentally, one of the persons whom the
World Bank
Team had identified as a "Health Policy Expert" was the then Secretary, who
had then recently been transferred to the the Health Department from some
other Ministry. He was later identified by Davdson Gwatkin, the Director of
the World Bank Center for Health Policy Studies at Washington to prepare a
health policy document for India. It would be interesting to know whether
that document was used in formulating the 2001 Draft. I had also discussed
these issues in
considerable detail in my book, HEALTH POLICIES AND PROGRAMMES IN INDIA IN
THE EIGHTIES: A CRITICAL APPRAISAL (New Delhi, Lok Paksh,1990).
III. THE NATIONAL HEALTH POLICY OF 1982-3 AND THE 2001 DRAFT
zof4
9/10/01 12:1C rV
rpha-ncc]'2001 Draft Health policy
7. One of the features of the 2001 Draft which strikes one with great force
is
the almost a total neglect of the postulates of the NHP of 1982. Under these
circumstances; it is not surprising to find any mention whatsoever of the
Alma Ata Declaration on Primary Health Care, or the 1977 Programme of
entrusting 'Peoples’ Health on Peoples' Hands", what to speak of the Bhore
Committee Report_of 1946 or that of the Sokhey Committee of 1942 .,
magnum
I had devoted a great deal of attention to the NHP-1982 in the
opus I
wrote in 1985, with the title: HEALTH AND FAMILY PLANNING SERVICES IN INDIA;
AN EPIDEMIOLOGICAL, SOCIO-CULTURAL AND A POLITICAL ANALYSIS AND A
PERSPECTIVE. I was apparently somewhat naive in expecting some movement,
particularly as it has the approval of the Parliament.
I would quote from the NHP1982 to underline a most deplorable infirmity of
the 2001 Draft: "THE
PRESENT SITUATION HAS BEEN LARGELY ENGENDERED BY THE ALMOST WHOLESALE
ADOPTION OF THE HEALTH MANPOWER AND ESTABLISHMENT OF CURATIVE CENTRES BASED
ON THE WESTERN MODELS, WHICH ARE INAPPROPRIATE AND IRRELEVANT TO THE REAL
NEEDS OF THE PEOPLE AND THE SOCIO-ECONOMIC CONDITIONS OBTAINING IN THE
COUNTRY ...... MEDICAL SERVICES HAS (SIC!) PROVIDED BENEFITS TO THE UPPER
CRUSTS OF THE SOCIETY, SPECIALLY THOSE LIVING IN URBAN AREAS....... THE
EXISTING APPROACH, INSTEAD OF IMPROVING AWARENESS AND BUILDING UP
SELF-RELIANCE, HAS ENHANCED DEPENDENCY TVND WEAKENED COMMUNITY'S CAPACITY TO
COPE WITH ITS PROBLEMS.'
How could the authors of the draft wish away the NHP1982? Did they analyse
why this policy remained virtually unimplemented? How can they come forward
with the 2001 Draft without giving assurance to the people of India that a
similar fate will not befall on whatever they have said in the Draft?
IV. LITTLE ANALYSIS OF THE CURRENT SITUATION
8. The Report of the Independent Commission on Health in India, the two
rounds of the National Family Health Survey, the NSS and the NCAER Surveys
on utilisation^of medical care in India and data from the Ninth Five Year
Plan document and its Mid-Term Appraisal and from its Programme Evaluation
Organisation, all point to an advanced state of decay of theTealtli
Services in India. At a somewhat lower level, d^istri rt .-w_i de study of the
health service__sysiLanL in Thriasur—by C K Jagadeesan—(HEALTH FOR THE
MTWiONSt no. 271997) also presented a very dismal picture in the much
adulated State of Kerala. He found that as many as 80 per cent of the
doctors do not live in the primary health centres of the districts; they are
busy with private practice in nearby towns. Many do not even turn up at the
PHC on some days.
Analysis of the existing state of affairs with a view to finding policy
options do not find any place in the Draft.
V. PROSPECTS OF IMPLEMENTING THE PROPOSED POLICY
foregoing analysis of the methodology used, experience of the past
9. The
*
and
the present situations leads to the very compelling conclusion that the
implementation of the Policy will meet the same fate as the NHP 1982. It
status
quo
will end as a p
]_ rescription for the
______
’
. . -People, including the poor,
will be forced to fall back on the greedy merchants of the private sector.
V
A FRAMEWORK FOR STRIVING TOWARDS AN ALTERNATIVE POLICY
10. Problems of policy formulation and its implementation is rooted in the
3of4
9/10/01 I2.1CPM
fpha-ncc} 2001 »Draft Health policy
power structure prevailing in the country. It is essentially a political
question. So the initiative must come from the political level. If the
political leadership at the state and Union levels muster the strength to
remedy the situation, a prescription for the malady that afflicts the health
service system of the country can be found. I have written a 83-Chapter,
1400 computer page manuscript entitled: INDIA'S FORGOTTEN PEOPLE AND THE
SICKNESS, OF THE PUBLIC HEALTH SERVICE SYSTEM: A PRESCRIPTION FOR THE MALADY.
I have published a summary of this work in HEALTH FOR THE MILLIONS
(nos.4-6,1997). This contains detailsof short term and long term policy
action that can be taken to remedy the situation.
Shri Javed Chowdhury
Ms Sujata Rao
----------------------- Yahoo! Groups Sponsor
Get your FREE credit report with a FREE Creditcheck
Monitoring Service trial
http://us.click.yahoo.com/MDsVHB/b08CAA/ySSFAA/xYTolB/TM
To unsubscribe from this group, send an email to:
pha-ncc-unsubscribe@egroups.com
Your use of Yahoo1 Groups is subject to http://docs.yahoo.com/info/terms/
4 of 4
9/10/01 12/10 PM
■'.V
RF- fnifnendcirclel National Health Policy
■
1
I
absence.
' 1I
We are looking forward to a!! your comments.
Abhijit/Ramakant
X:J
To' unsubscribe from this group, send ah email to:
mfriendcircl8-unsubscribe@egroups.com ,
Your use of Yahoo! Groups is subject to theYahoo! Termsof Sarvice.<
J
•' '«<
■i-
■
5
a
Incoming mail is certified Virus Free.
Checked by AVG anti-virus system (www.grisoft.com ).
Version: 6.0.276 / Virus Database: 145 - Release Date: 9/3/01
"T
*
ADX/prtisFMENT
:! !.r. . ...
.
I
i
;
■?-
$
f
...
r i- .
'* i
' *
’■’tr
■
t
-------- -—M—
Ld.
______________ '
■-
m!^..
-
.;-<y
i ?■
'
To unsubscribe from this group, send an email to:A,
mfriendcircle-unsubscribe@egroups.com
Your use of Yahoo! Grouus is subject to the Yahoo! Terms of Service.
'';4
——
r
Outgoing mail is certified Virus Free
Checked by AVG anti-virus system (www nrisoft.com)
Version: 6.0.276 / Virus Database: 1*15 - Release Date: 9/3/01
2 of 2
/■ .-4 • t
t
9/K/01
1-
I
I
a
RE- (mfriendcirclel National Health Policy
Subject: RE: [mfrieudcirck] National Health Policy
Date: Fn, 7 Sep 2001 20:55:33+0530
From: "Arun & Vandana Prasad" <arunprasad@^’snl.com>
Reply-To: mfriendcircle@yahoogroups.com
To: <mfnendcircle@yahoogroups.com>
CC: "forces" <forces@vsnl.com>, <rafaykhan25@yahoo.com>
1? !
PLEASE NOTE THAT CHILDREN ARE HARDLY MENTIONED LEAVE ALONE A SEPERATE SECTION FOR THEM!
THIS IS VERY SERIOUS PLEASE RESPOND TO THIS ISSUE ALSO IN ALL RECOMMNEDATIONS
vandana prasad
forces and pediatrician
—Original Message—
From: sentto-1907861-866-999844590-amnprasad=vsnl.com@retums.oneistconi
«
[mailto:sentto-1507861-866-999844590-arunprasad=vsnl.com@retums.onelist.com]On Behalf Of abhijit
Sent: Friday, September 07, 2001 11:25 AM
To: mfriendcirde@yahoogroups.com
Subject: [mfrienddrde] National Health Policy
1
Dear Everyone,
The Draft National Health Policy ends off by saying that comments by 30 days, and I think a week fe about
to be over. Has any one made a critique. We need to send in our comments fast, as this may be arj
opportunity to get things changed. I am not very equipped to make policy critiques, and the policy looks .. -.•<!
progressive. Some of the things that we felt should be included ■
’ ■
..........
•'
f
Firstly after talking at lengths about equity and the fact that the public health system should be made to
I
serve 75 % of needs there is no mention of a grievance redressal mechanism- this is perhaps from the fact ’
that health is still not considered a right.
The second thing that struck us was that while mentioning the fact that medical curriculum needs to be 4
revised the revision is intended only in the technical spheres. If equity is a major objective, the medical
M
education system should also include social equity issues as a subject area.
Another area of concern is the stated objective of encouraging foreign patients - what could be the possible
impact on the local patients?
There is no mention of the health needs of special populations - eg, the elderly, disaster affected peoples/
tribals etc.
/
f
There is a mention of the people who can pay should pay for public health services - but how will the
people who cannot pay be identified- this has always been a problem in our setting- the apl/bpl divide!
.
'
'
a
I
'
The increase in budgetary allocation for the primary sector is welcome- we are wondering whatthe
implications of reduction of budget in the secondary tertiary sector, with emphasis on private sector
particioation at this level and encouragement of overseas patients - will have on the poor but needy
, person
- n
-
•
i
The mention of urban public health system is laudable- in section two (2.9) - current scenario - slums are
specifically mentioned - while in section four (4.9) this specific mention is absent - we were wondering
4
whether this is intentional!
The deliberate mention of not setting up any research ethic guidelines and the opening of research for
private entrepreneurship, sounds somewhat contradictory to the interest of the people?
•
.
-
j ■
1
•; .
■ Wap
The monitoring of the public health system is mentioned in section 4.3.1 - where the implementation will be
done by autonomous bodies ( setting up new GONGOs we guess) while the monitoring will be done by
State government. The other mention is in the section on IEC where it is explicitly mentioned that the work ; '. .B
of PRI/NGOs and Trusts will be done as per targets. The role of PRIs in monitoring is Conspicuous by its
.i-
loff
a)
..p
:4
9/10/01 ’
1
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
- 2-0- 8
DRAFT NATIONAL HEALTH POLICY - 2001
1. 1NTRODLCTORY
1.1 A National Health Policy was last formulated in 1983 and since then, there have been
very marked changes in the determinant factors relating to the health sector. Some of the
policy initiatives outlined in the NHP-1983 have yielded results, while in several other
areas, the outcome has not been as expected.
1.2 The NHP-1983 gave a general exposition of the recommended policies required in
the circumstances then prevailing in the health sector. The noteworthy initiatives under
that policy were
A phased, time-bound programme for setting up a well-dispersed network of
comprehensive primary health care services, linked with extension and health
education, designed in the context of the ground reality that elementary health
problems can be resolved by the people themselves;
ii. Intermediation through ‘Health volunteers’ having appropriate knowledge, simple
skills and requisite technologies;
iii. Establishment of a well-worked out referral system to ensure that patient load at the
higher levels of the hierarchy is not needlessly burdened by those who can be
treated at the decentralized level;
iv. An integrated net-work of evenly spread speciality and super-speciality services;
encouragement of such facilities through private investments for patients who can
pay, so that the draw on the Government’s facilities is limited to those entitled to
free use.
i.
1.3 Government initiatives in the pubic health sector have recorded some noteworthy
successes over time. Smallpox and Guinea Worm Disease have been eradicated from the
country; Polio is on the verge of being eradicated; Leprosy, Kala Azar, and Filariasis can
be expected to be eliminated in the foreseeable future. There has been a substantial drop
in the Total Fertility Rate and Infant Mortality Rate. The success of the initiatives taken
in the public health field are reflected in the progressive improvement of many
demographic / epidemiological / infrastructural indicators over time - (Box-I).
Box-1 : Through The Years - 1951-2000Achieveineiits
i;
..
Indicator
1951
1981
2000
Life Expectancy
36.7
54
64.6(RGI)
Crude Birth Rate
40.8
33.9(SRS)
26.1(99 SRS)
Crude Death Rate
25
12.5(SRS)
8.7(99 SRS)
IMR
146
110
70 (99 SRS)
Demographic Changes
1 of 22
9/6/01 4:20 PM
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
1
Epidemiological Shifts
Malaria (cases in million)
75
2.7
2.2
Leprosy cases per 10,000
population
38.1
57.3
3.74
Small Pox (no of cases)
>44,887
Eradicated
Guineaworm ( no. of cases)
>39,792
Eradicated
Polio
29709
265
57,363
1,63,181
Sit
Infrastructure
SC/PHC/CHC
725
(99-RHS)
Dispensaries &Hospitals( all)
9209
23,555
43,322
(95-96-CBHI)
Beds (Pvt & Public)
117,198
569,495
8,70,161
(95-96-CBHI)
Doctors(Allopathy)
61,800
2,68,700
5,03,900
(98-99-MCI)
Nursing Personnel
18,054
1,43,887
7,37,000
(99-INC)
1.4 While noting that the public health initiatives over the years have contributed
significantly to the improvement of these health indicators, it is to be acknowledged that
public health indicators / disease-burden statistics are the outcome of several
complementary initiatives under the wider umbrella of the developmental sector,
covering Rural Development, Agriculture, Food Production,“Sanitation, Drinking Water
Supply, Education, etc. Despite the impressive public health gains as revealed in the
statistics in Box-I, there is no gainsaying the fact that the morbidity and mortality levels
in the country are still unacceptably high. These unsatisfactory health indices are, in turn,
an indication of the limited success of the public health system to meet the preventive
and curative requirements of the general population.
1.5 Out of the communicable diseases, which have persisted over history, incidence of
Malaria has staged a resurgence in the 1980s before stabilising at a fairly high prevalence
Tevel during the 1990s. Over the years, an increasing level of insecticide-resistance has
developed in the malarial vectors in many parts of the country, while the incidence of the
more deadly P-Falciparum Malaria has risen to about 50 percent in the country as a
2 of 22
9/6/01 4:28 PM
file:///D|/EMAILRECEIVED/nationalhealthpolic.htm
I
whole. In respect of TB, the public health scenario has not shown any significant decline
in the pool of infection amongst the community, and, there has been a distressing trend
in increase of drug resistance in the type of infection prevailing in the country. A new
and extremely virulent communicable disease - HIV/AIDS - has emerged on the health
scene since the declaration of the NHP-1983. As there is no existing therapeutic cure or
vaccine for this infection, the disease constitutes a serious threat, not merely to public
health but to economic development in the country. The common water-borne infections
- Gastroenteritis, Cholera, and some forms of Hepatitis - continue to contribute to a high
level of morbidity in the population, even though the mortality rate may have been
somewhat moderated. The period after the announcement of NHP-83 has also seen an
increase in mortality through ‘life-style’ diseases- diabetes, cancer and cardiovascular
diseases. The increase in life expectancy has increased the requirement for geriatric care.
Similarly, the increasing burden of trauma cases is also a significant public "health
problem. The changed circumstancesTelating to the health sector of the country since
1983 have generated a situation in which it is now necessary to review the field, and to
formulate a new policy framework as the National Health Policy-2001.
1.6 NHP-2001 will attempt to set out a new policy framework for the accelerated
achievement of Public health goals in the socio-economic circumstances currently
prevailing in the country.
2, CURRENT SCENARIO
2.1 FINANCIAL RESOURCES
The public health investment in the country over the years has been comparatively low,
and as a percentage of GDP has declined from 1.3 percent in 1990 to 0.9 percent in 1999.
The aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of this,
about 20 percent of the aggregate expenditure is public health spending, the balance
being out-of-pocket expenditure. The central budgetary allocation for health over this
period, as a percentage of the total Central Budget, has been stagnant at 1.3 percent,
while that in the States has declined from 7.0 percent to 5.5 percent. The current annual
per capita public health expenditure in the country is no more than Rs. 160. Given these
statistics, it is no surprise that the reach and quality of public health services has been
below the desirable standard. Under the constitutional structure, public health is the
responsibility of the States. In this framework, it has been the expectation that the
principal contribution for the funding of public health services will be from States’
resources, with some supplementary input from Central resources. In this backdrop, the
contribution of Central resources to the overall public health funding has been limited to
about 15 percent. The fiscal resources of the State Governments are known to be very
inelastic. This itself is reflected in the declining percentage of State resources allocated
to the health sector out of the State Budget. If the decentralized pubic health services in
the country are to improve significantly, there is a need for injection of substantial
resources into the health sector from the Central Government Budget. This approach,
despite the formal Constitutional provision in regard to public health, is a necessity if the
State public health services - a major component of the initiatives in the social sector are not to become entirely moribund. The NHP-2001 has been formulated taking into
consideration these ground realities in regard to the availability of resources.
3 of 22
9/6/01 4:29 PM
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
1
2.2 EQUITY
2.2.1 In the period when centralized planning was accepted as a key instrument of
development in the country, the attainment of an equitable regional distribution was
considered one of its major objectives. Despite this conscious focus in the development
process, the statistics given in Box-II clearly indicate that attainment of health indices
have been very uneven across the rural - urban divide.
Box II : Differentials in Health Status Among States
Population
BPL (%)
Sector
IMR/
<5Mort-ality
Per 1000
per 1000
(NFHS II)
Live Births
(1999-SRS)
Weight
For Age-
% of
Children
Under 3
years
MMR/
Leprosy
cases per
Lakh
(Annual
Report
2000)
10000
popula-tion
408
3.7
Malaria
+ve
Cases in
year
2000 (in
thousands)
(<-2SD)
India
26.1
70
94.9
47
Rural
27.09
75
103.7
49.6
Urban
23.62
44
63.1
38.4
2200
A
Better
Performing
States
Kerala
12.72
14
18.8
27
87
0.9
5.1
Maharastra
25.02
48
58.1
50
135
3.1
138
TN
21.12
52
63.3
37
79
4.1
56
Orissa
47.15
97
104.4
54
498
7.05
483
Bihar
42.60
63
105.1
54
707
11.83
132
Low
Performing {
States
Rajasthan
T
15.28
81
114.9
51
607
0.8
53
UP
I
31.15
84
122.5
52
707
4.3
99
37.43
90
137.6
55
498
3.83
528
MP
Also, the statistics bring out the wide differences between the attainments of health goals
in the better- performing States as compared to the low-performing States. It is clear that
national averages of health indices hide wide disparities in public health facilities and
health standards in different parts of the country. Given a situation in which national
averages in respect of most indices are themselves at unacceptably low levels, the wide
4 of 22
9/6/01 4:29 PM
1
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
inter-State disparity implies that, for vulnerable sections of society in several States,
access to public health services is nominal and health standards are grossly inadequate.
Despite a thrust in the NHP-1983 for making good the unmet needs of public health
services by establishing more public health institutions at a decentralized level, a large
gap in facilities still persists. Applying current norms to the population projected for the
year 2000,dt is estimated that the shortfall in the number of SCs/PHCs/CHCs is of the
order of 16 percent. However, this shortage is as high as 58 percent when disaggregated
for CHCs only. The NHP-2001 will need to address itself to making good these
deficiencies so as to narrow the gap between the various States, as also the gap across the
rural-urban divide.
2.2.2 Access to, and benefits from, the public health system have been very uneven
between the better-endowed and the more vulnerable sections of society. This is
particularly true for women, children and the socially disadvantaged sections of society.
The statistics given in Box-Ill highlight the handicap suffered in the health sector on
account of socio-economic inequity.
Box-Ill : Differentials in Health status Among Socio-Economic Groups
Infant
Mortality/1000
Under 5
Mortality/1000
% Children
70
94.9
47
83
119.3
53.5
84.2
126.6
55.9
Other Disadvantaged
76
103.1
47.3
Others
61.8
82.6
41.1
Indicator
India
Underweight
Social Inequity
Scheduled Castes
Scheduled Tribes
I
2.2.3 It is a principal objective of NHP-2001 to evolve a policy structure which reduces
these inequities and allows the disadvantaged sections of society a fairer access to public
health services.
J
2.3 DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
9
5 of 22
2.3.1 It is self-evident that in a country as large as India, which has a wide variety of
socio-economic settings, national health programmes have to be designed with enough
flexibility to permit the State public health administrations to craft their own programme
package according to their needs. Also, the implementation of the national health
programme can only be carried out through the State Governments’ decentralized public
health machinery. Since, for various considerations, the responsibility of the Central
Government in funding additional public health services will continue over a period of
time, the role of the Central Government in designing broad-based public health
initiatives will inevitably continue. Moreover, it has been observed that the technical and
managerial expertise for designing large-span public health programmes exists with the
9/6/01 4:29 PM
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
I
Central Government in a considerable degree; this expertise can be gainfully utilized in
designing national health programmes for implementation in varying socio-economic
settings in the states.
2.3.2 Over the last decade or so, the Government has relied upon a ‘vertical’
implementational structure for the major disease control programmes. Through this, the
system has been able to make a substantial dent in reducing the burden of specific
diseases. However, such an organizational structure, which requires independent
manpower for each disease programme, is extremely expensive and difficult to sustain.
Over a long time-range, ‘vertical’ structures may only be affordable for diseases, which
offer a reasonable possibility of elimination or eradication in a foreseeable time-span. In
this background, the NHP-2001 attempts to define the role of the Central Government
and the State Governments in the public health sector of the country.
2.4 THE STATE OF PUBLIC HEALTH INFRA-STRUCTURE
2.4.1 The delineation ofNHP-2001 would be required to be based on an objective
assessment of the quality and efficiency of the existing public health machinery in the
field. It would detract from the quality of the exercise if, while framing a new policy, it
is not acknowledged that the existing public health infrastructure is far from satisfactory.
For the out-door medical facilities in existence, funding is generally insufficient; the
presence of medical and para-medical personnel is often much less than required by the
prescribed norms; the availability of consumables is frequently negligible; the equipment
in many public hospitals is often obsolescent and unusable; and the buildings are in a
dilapidated state. In the in-door treatment facilities, again, the equipment is often
obsolescent; the availability of essential drugs is minimal; the capacity of the facilities is
grossly inadequate, which leads to over-crowding, and consequentially to a steep
deterioration in the quality of the services. As a result of such inadequate public health
facilities, it has been estimated that less than 20 percent of the population seeks the OPD
services and less than 45 percent avails of the facilities for in-door treatment in public
hospitals. This is despite the fact that most of these patients do not have the means to
make out-of-pocket payments for private health services except at the cost of other
essential expenditure for items such as basic nutrition.
2.5 EXTENDING PUBLIC HEALTH SERVICES
2.5.1 While in the country generally there is a shortage of medical manpower, this
shortfall is disproportionately impacted on the less-developed and rural areas. No
incentive system attempted so far, has induced private medical manpower to go to such
areas; and, even in the public health sector it has usually been a losing battle to deploy
medical manpower in such under-served areas. In such a situation, the possibility needs
to be examined for entrusting some limited public health functions to nurses, paramedics
and other personnel from the extended health sector after imparting adequate training to
them.
2.5.2 India has a vast reservoir of practitioners in the Indian Systems of Medicine and
Homoeopathy, who have undergone formal training in their own disciplines. The
possibility of using such practitioners in the implementation of State/Central
Government public health Programmes, in order to increase the reach of basic health
6 of 22
9/6/01 4:29 PM
1
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
care in the country, is addressed in the NHP-2001.
2.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS
2.6.1 Some States have adopted a policy of devolving programmes and funds in the
health sector through different levels of the Panchayati Raj Institutions. Generally, the
experience has been a favourable one. The adoption of such an organisational structure
has enabled need-based allocation of resources and closer supervision through the
elected representatives. NHP- 2001 examines the need for a wider adoption of this mode
of delivery of health services, in rural as well as urban areas, in other parts of the
country.
2.7 MEDICAL EDUCATION
2.7.1 Medical Colleges are not evenly spread across various parts of the country. Apart
from the uneven geographical distribution of medical institutions,,the quality of
education is highly uneven and in several instances even sub-standard. It is a common
perception that the syllabus is excessively theoritical, making it difficult for the fresh
graduate to effectively meet even the primary health care needs of the population. There
bis an understandable reluctance on the part of graduate doctors to serve in areas distant
7 from theif native place. NHP-2001 will suggest policy initiatives to rectify these
disparities. ,
2.7.2 Certain medical discipline, such as, molecular biology and gene-manipulation,
have become relevant in the period after the formulation of the previous National Health
Policy. Also, certain speciality disciplines - Anesthesiology, Radiology and Forensic
Medicines - are currently very scarce, resulting in critical deficiencies in the package of
available public health services. The components of medical research in the recent years
have changed radically. In the foreseeable future such research will rely increasingly on
such new disciplines. It is observed that the current under-graduate medical syllabus
does not cover such emerging subjects. NHP-2001 will make appropriate
recommendations in this regard.
2.8 NEED FOR SPEC IALISTS IN ‘PUBLIC HEALTH’ AND ^FAMILY MEDICINE’
2.8.1 In any developing country with inadequate availability of health services, the
requirement of expertise in the areas of‘public health’ and ‘family medicine’ is very
much more than the expertise required for other specialized clinical disciplines. In India,
the situation is that public health expertise is non-existent in the private health sector,
and far short of requirement in the public health sector. Also, the current curriculum in
the graduate / post-graduate courses is outdated and unrelated to contemporary
community needs. In respect of ‘family medicine’, it needs to be noted that the more
talented medical graduates generally seek specialization in clinical disciplines, while the
remaining go into general practice. While the availability of postgraduate educational
facilities is 50 percent of the total number of the qualifying graduates each year, and can
be considered adequate, the distribution of the disciplines in the postgraduate training
facilities is overwhelmingly in favour of clinical specializations. NHP-2001 examines
the need for ensuring adequate availability of personnel with specialization in the ‘public
health’ and ‘family medicine’ disciplines, to discharge the public health responsibilities
in the country.
7 of 22
9/6/01 4:29 PM
1
r
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
2.9 URBAN HEALTH
2.9.1 In most urban areas, public health services are very meagre. To the extent that such
services exist, there is no uniform organisational structure, The urban population in the
country is presently as high as 30 percent and is likely to go up to around 33 percent by
2010. The bulk of the increase is likely to take place through migration, resulting in
slums without any infrastructure support. Even the meagre public health services
available do not percolate to such unplanned habitations, forcing people to avail of
private health care through out-of-pocket expenditure. The rising vehicle density in large
urban agglomerations has also led to an increased number of serious accidents requiring
treatment in well-equipped trauma centres. NHP-2001 will address itself to the need for
providing this unserved population a minimum standard of health care facilities.
2.10 MENTAL HEALTH
2.10.1 Mental health disorders are actually much more prevalent than are visible on the
surface. While such disorders do not contribute significantly to mortality, they have a
serious bearing on the quality of life of the affected persons and their families. Serious
cases of mental disorder require hospitalization and treatment under trained supervision.
Mental health institutions are perceived to be woefully deficient in physical
infrastructure and trained manpower. NHP-2001 will address itself to these deficiencies
in the public health sector.
2.11 INFORMATION, EDUCATION AND COMMUNICATION
2.11.1 A substantial component of primary health care consists of initiatives for
disseminating, to the citizenry, public health-related information. Public health
programmes, particularly, need high visibility at the decentralized level in order to have
any impact. This task is particularly difficult as 35 percent of our country’s population is
illiterate. The present IEC strategy is too fragmented, relies heavily on mass media and
does not address the needs of this segment of the population. It is often felt that the
effectiveness of IEC programmes is difficult to judge; and consequently, it is often
asserted that accountability, in regard to the productive use of such funds, is doubtful.
NHP-2001, while projecting an IEC strategy, will fully address the inherent problems
encpuntered in any IEC programme designed for improving awareness in order to bring
about behavioural change in the general population.
2.11.2 It is widely accepted that school and college students are the most receptive
targets for imparting information relating to basic principles of preventive health care.
NHP-2001 will attempt to target this group to improve the general level of health
awareness.
2.12 MEDICAL RESEARCH
2.12.1 Over the years, medical research activity in the country has been very limited. In
the Government, such research has been confined to the research institutions under the
Indian Council of Medical Research, and other institutions funded by the States/Central
Government. Research in the private sector has assumed some significance only in the
last decade. In our country, where the aggregate annual health expenditure is of the order
8 of 22
9/6/01 4:29 PM
I
file:///D|/EMAILRECEIVED/nationalhealthpolic.htm
^1
of Rs. 80,000 crores, the expenditure in 1998-99 on research, both public and private
sectors, was only of the order of Rs. 1150 crores. It would be reasonable to infer that
with such low research expenditure, it would be virtually impossible to make any
dramatic break-through within the country, by way of new molecules and vaccines; also,
without a minimal back-up of applied and operational research, it would be difficult to
assess whether the health expenditure in the country is being incurred through optimal
applications and appropriate public health strategies. Medical Research in the country
needs to be focused on therapeutic drugs/vaccines for tropical diseases, which are
normally neglected by international pharmaceutical companies on account of limited
profitability potential. The thrust will need to be in the newly-emerging frontier areas of
research based on genetics, genome-based drug and vaccine development, molecular
biology, etc. NHP-2001 will address these inadequacies and spell out a minimal quantum
of expenditure for the"coming decade, looking to the national needs and the capacity of
the research institutions to absorb the funds.
2.13 ROLE OF THE PRIVATE SECTOR
2.13.1 Considering the economic restructuring underway in the country, and over the
globe, since the last decade, the changing role of the private sector in providing health
care will also have to be addressed in NHP 2001. Currently, the contribution of private
health care is principally through independent practitioners. Also, the private sector
contributes significantly to secondary-level care and some tertiary care. With the
increasing role of private health care, the need for statutory licensing and monitoring of
rmhimum standards of diagnostic centres / medical institutions becomes imperative.
NHP-2001 will address the issues regarding the establishment of a regulatory
mechanism to ensure adequate standards of diagnostic centres / medical institutions,
conduct of clinical practice and delivery of medical services.
2.13.2 Currently, non-Govemmental service providers are treating a large number of
patients at the primary level for major diseases. However, the treatment regimens
followed are diverse and not scientifically optimal, leading to an increase in the
incidence of drug resistance. NHP-2001 will address itself to recommending
arrangements, which will eliminate the risks arising from inappropriate treatment.
2.13.3 The increasing spread of information technologt raises the possibility of its
adoption in the health sector. NHP-2001 will examine this possibility.
2.14 ROLE OF THE CIVIL SOCIETY —
2.14.1 Historically, the practice has been to implement major national disease control
programmes through the public health machinery of the State/Central Governments. It
has become increasingly apparent that certain components of such programmes cannot
be efficiently implemented merely through government functionaries. A considerable
change in the mode of implementation has come about in the last two decades, with an
increasing involvement of NGOs and other institutions of civil society. It is to be
recognized that widespread debate on various public health issues have, in fact, been
initiated and sustained by NGOs and other members of the civil society. Also, an
increasing contribution is being made by such institutions, in the delivery of different
components of public health services. Certain disease control programmes require close
9 of 22
9/6/01 4:29 PM
file:///D[/EMAip RECEIVED/nationalhealthpolic.htm
1
Po-rt. /
inter-action with the beneficiaries for regular administration of drugs; periodic carrying
out of the pathological tests; dissemination of information regarding disease control and
other general health information. NHP-2001 will address such issues and suggest policy
instruments for implementation of public health programmes through individuals and
institutions of civil society.
2.15 NATIONAL DISEASE SURVEILLANCE NETWORK
)
i
2.15.1 The technical network available in the country for disease surveillance is
extremely rudimentary and to the extent that the system exists, it extends only up to the
district level. Disease statistics are not flowing through an integrated network from the
decentralized public health facilities to the State/Central Government health
administration. Such an arrangement only provides belated information, which, at best,
serves a limited statistical purpose. The absence of an efficient disease surveillance
network is a major handicap in providing a prompt and cost effective health care system.
The efficient disease surveillance network set up for Polio and HIV/AIDS has
demonstrated the enormous value of such a public health instrument. Real-time
information of focal outbreaks of common communicable diseases - Malaria, GE,
Cholera and JE - and other seasonal trends of diseases, would enable timely
intervention, resulting in the containment of any possible epidemic. In order to be able to
use an integrated disease surveillance network, for operational purposes, real-time
information is necessary at all levels of the health administration. NHP-2001 would
address itself to this major systemic shortcoming in the administration.
2.16 HEALTH STATISTICS
2.16.1 The absence of a systematic and scientific health statistics data-base is a major
deficiency in the current scenario. The health statistics collected are not the product of a
rigorous methodology. Statistics available from different parts of the country, in respect
of major diseases, are often not obtained in a manner which make aggregation possible,
or meaningful.
■ r f7'
2.16.2 Further, absence of proper and systematic documentation of the various financial
resources used in the health sector is another lacunae witnessed in the existing scenario.
This makes it difficult to understand trends and levels of health spending by private and
public providers of health care in the country, and to address related policy issues and
formulate future investment policies.
2.16.3 NHP-2001 will address itself to the programme for putting in place a modem and
scientific health statistics database as well as a system of national health accounts.
2.17 WOMEN’S HEALTH
2.17.1 Social, cultural and economic factors continue to inhibit women from gaining
adequate access to even the existing public health facilities. This handicap does not just
affect women as individuals; it also has an adverse impact on the health, general
well-being and development of the entire family, particularly children. NHP 2001
recognises the catalytic role of empowered women in improving the overall health
standards of the community.
10 of 22
9/6/01 4:29 PM
1
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
2.18 MEDICAL ETHICS
H’
2.18.1 Professional medical ethics in the health sector is an area, which has not received
much attention in the past. Also, the new frontier areas of research - involving gene
manipulation, organ/human cloning and stem cell research impinge on visceral issues
relating to the sanctity of human life and the moral dilemma of human intervention in the
designing of life forms. Besides these, in the emerging areas of research, there is an
un-charted risk of creating new life forms, which may irreversibly damage the
environment, as it exists today. NHP - 2001 recognises that moral and religious dilemma
of this nature, which was not relevant even two years ago, now pervades mainstream
health sector issues.
2.19 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DREGS
2.19.1 There is an increasing expectation and need of the citizenry for efficient
enforcement of reasonable quality standards for food and drugs. Recognizing this need,
NHP - 2001 makes an appropriate policy recommendation.
2.20 REGULATION OF STANDARDS IN PARA MEDICAL DISCIPLINES
2.20.1 It has been observed that a large number of training institutions have mushroomed
particularly in the private sector, for several para medical disciplines - Lab Technicians,
Radio Diagnosis Technicians, Physiotherapists, etc. Currently, there is no
regulation/monitormg of the curriculum, or the performance of the practitioners in these
disciplines. NHP-2001 will make recommendations to ensure standardization of training
and monitoring of performance.
2.21 OCCUPATIONAL HEALTH
2.21.1 Work conditions in several sectors of employment in the country are
sub-standard. As a result of this, workers engaged in such activities become particularly
prone to occupation-linked ailments. The long-term risk of chronic morbidity is
particularly marked in the case of child labour. NHP-2001 will address the risk faced by
this particularly vulnerable section of the society.
2.22 PROVIDING MEDICAL FACILITIES TO USERS FROM OVERSEAS
2.22.1 The secondary and tertiary facilities available in the country are of good quality
and cost-effective compared to international medical facilities. This is true not only of
facilities in the allopathic disciplines, but also to those belonging to the alternative
systems of medicine, particularly Ayurveda. NHP-2001 will assess the possibilities of
encouraging commercial medical services for patients from overseas.
2.23 IMPACT OF GLOBALIZATION ON THE HEALTH SECTOR
2.23.1 There are some apprehensions about the possible adverse impact of economic
globalisation on the health sector. Pharmaceutical drugs and other health services have
always been available in the country at extremely inexpensive prices. India has
established a reputation for itself around the globe for innovative development of
original process patents for the manufacture of a wide-range of drugs and vaccines
within the ambit of the existing patent laws. With the adoption of Trade Related
11 of 22
9/6/01 4:29 PM
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
1
Intellectual Property (TRIPS), and the subsequent alignment of domestic patent laws
consistent with the commitments under TRIPS, there will be a significant shift in the
scope of the parameters regulating the manufacture of new drugs/vaccines. Global
experience has shown that the introduction of a TRIPS-consistent patent regime for
drugs in a developing country, would result in an increase in the cost of drugs and
medical services. NHP-2001 will address itself to the future imperatives of health
security in the country, in the post-TRIPS era.
2.24 NON - HEALTH DETERMINANTS
2.24.1 Improved health standards are closely dependent on major non-health
determinants such as safe drinking water supply, basic sanitation, adequate nutrition,
clean environment and primary education, especially of the girl child, NHP-2001 will
not explicitly address itself to the initiatives in these areas, which although crucial, fall
, outside the domain of the health sector. However, the attainment of the various targets
set in NHP 2001 assumes a reasonable performance in these allied sectors.
2.25 POPULATION GROWTH AND HEALTH STANDARDS
2.25.1 Efforts made over the years for improving health standards have been neutralized
by the rapid growth of the population. Unless the Population stabilization goals are
achieved, no amount of effort in the other components of the public health sector can
bring about significantly better national health standards. Government has separately
announced the 'National Population Policy - 2000’. The principal common features
covered under the National Population Policy-2000 and NHP-2001, relate to the
prevention and control of communicable diseases; priority to containment of HIV/AIDS
infection; universal immunization of children against all major preventable diseases;
addressing the unmet needs for basic and reproductive health services; and
supplementation of infrastructure. The synchronized implementation of these two
Policies - National Population Policy - 2000 and National Health Policy-2001 - will be
the very cornerstone of any national structural plan to improve the health standards in
the country.
2.26 ALTERNATIVE SYSTEMS OF MEDICINE
2.26.1 Alternative Systems of Medicine - Ayurveda, Unani, Sidha and Homoeopathy provide a significant supplemental contribution to the health care services in the country,
particularly in the underserved, remote and tribal areeas. The main components of
NHP-2001 apply equally to the alternative systems of medicine. However, the policy
features specific to the alternative systems of medicine will be presented as a separate
document.
3. OBJECTIVES
3.1 The main objective of NHP-2001 is to achieve an acceptable standard of good health
amongst the general population of the country. The approach would be to increase access
to the decentralized public health system by establishing new infrastructure in deficienr
areas, and by upgrading the infrastructure in the existing institutions. Overriding
importance would be given to ensuring a more equitable access to health services across
the social and geographical expanse of the country. Emphasis will be given to increasing
12 of 22
9/6/01 4:29 PM
1
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
O
the aggregate public health investment through a substantially increased contribution by
the Central Government. It is expected that this initiative will strengthen the capacity of
the public health administration at the State level to render effective service delivery.
The contribution of the private sector in providing health services would be much
enhanced, particularly for the population group, which can afford to pay for services.
Primacy will be given to preventive and first-line curative initiatives at the primary
health level through increased sectoral share of allocation. Emphasis will be laid on
rational use of drugs within the allopathic system. Increased access to tried and tested
systems of traditional medicine will be ensured. Within these broad objectives,
NHP-2001 will endeavour to achieve the time-bound goals mentioned in Box-IV.
Box-IV: Goals to be achieved by 2000-2015
• Eradicate Polio and Yaws
2005
• Eliminate Leprosy
2005
• Eliminate Kala Azar
2010
• Eliminate Lymphatic Filariasis
2015
• Achieve Zero level growth of HIV/AIDS
2007
• Reduce Mortality by 50% on account of TB, Malaria
and Other Vector and Water Borne diseases
2010
• Reduce Prevalence of Blindness to 0.5%
2010
. Reduce IMR to 30/1000 And MMR to 100/Lakh
2010
• Improve nutrition and reduce proportion of LBW
Babies from 30% to 10%
2010
• Increase utilisation of public health facilities from
current Level of <20 to >75%
2010
Establish an integrated system of surveillance, National
Health Accounts and Health Statistics.
2005
• Increase health expenditure by Government as a % of
GDP from the existing 0.9 % to 2.0%
2010
• Increase share of Central grants to Constitute at least
25% of total health spending
2010
• Increase State Sector Health spending from 5.5% to 7%
of the budget
2005
2010
Further increase to 8%
4. NHP-2()()1 - POLICY PRESCRIPTIONS
13 of 22
9/6/01 4:29 PM
1
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
4.1 FINANCIAL RESOURCES
The paucity of public health investment is a stark reality. Given the extremely difficult
fiscal position of the State Governments, the Central Government will have to play a key
role in augmenting public health investments. Taking into account the gap in health care
facilities under NHP-2001 it is planned to increase health sector expenditure to 6 percent
of GDP, with 2 percent of GDP being contributed as public health investment, by the '
year 2010. The State Governments would also need to increase the commitment to the
health sector. In the first phase, byj2005, they would be expected to increase the
commitment of their resources to 7 percent of the Budget; and, in the second phase, by
2010, to increase it to 8 percent of the Budget. With the stepping up of the public health
investment, the Central Government’s contribution would rise to 25 percent from the
existing 15 percent, by 2010. The provisioning of higher public health investments will
also be contingent upon the increase in absorptive capacity of the public health
administration so as to gainfully utilize the funds.
4.2 EQUITY
4.2.1 To meet the objective of reducing various types of inequities and imbalances inter-regional; across the rural - urban divide; and between economic classes - the most
cost effective method would be to increase the sectoral outlay in the primary health
sector. Such outlets give access to a vast number of individuals, and also facilitate
preventive and early stage curative initiative, which are cost effective. In recognition of
this public health principle, NHP-2001 envisages an increased allocation of 55 percent of
the total public health investment for the primary health sector; the secondary and
tertiary health sectors being targetted for 35 percent and 10 percent respectively.
NHP-2001 projects that the increased aggregate outlays for the primary health sector will
be utilized for strengthening existing facilities and opening additional public health
service outlets, consistent with the norms for such facilities.
4.3 DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
4.3.1 NHP-2001, envisages a key role for the Central Government in designing national
programmes with the active participation of the State Governments. Also, the Policy
ensures the provisioning of financial resources, in addition to technical support,
monitoring and evaluation at the national level by the Centre. However, to optimize the
utilization of the public health infrastructure at the primary level, NHP-2001 envisages
the gradual convergence of all health programmes under a single field administration.
Vertical programmes for control of major diseases like TB, Malaria and HIV/AIDS
would need to be continued till moderate levels of prevalence are reached. The
integration of the programmes will bring about a desirable optimisation of outcomes
through a convergence of all public health inputs. The policy also envisages that
programme implementation be effected through autonomous bodies at State and district
levels. State Health Departments’ interventions may be limited to the overall monitoring
of the achievement of programme targets and other technical aspects. The relative
distancing of the programme implementation from the State Health Departments will
give the project team greater operational flexibility. Also, the presence of State
Government officials, social activists, private health professionals and MLAs/MPs on
the management boards of the autonomous bodies will facilitate well-informed
14 of 22
9/6/01 4:29 PM
1
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
decision-making.
4.4 THE STATE OF PUBLIC HEALTH INFRASTRUCTURE
4.4.1 As has been highlighted in the earlier part of the Policy, the decentralized Public
health service outlets have become practically dysfunctional over large parts of the
country. On account of resource constraint, the supply of drugs by the State
Governments is grossly inadequate. The patients at the decentralized level have little use
for diagnostic services, which in any case would still require them to purchase
therapeutic drugs privately. In a situation in which the patient is not getting any
therapeutic drugs, there is little incentive for the potential beneficiaries to seek the
advice of the medical professionals in the public health system. This results in there
being no demand for medical services, and medical professionals, and paramedics often
absent themselves from their place of duty. It is also observed that the functioning of the
public health service outlets in the four Southern States - Kerala, Andhra Pradesh, Tamil
Nadu and Karnataka - is relatively better, because some quantum of drugs is distributed
through the primary health system network, and the patients have a stake in approaching
the Public health facilities. In this backdrop, NHP-2001 envisages the kick-starting of the
revival of the Primary Health System by providing some essential drugs under Central
Government funding through the decentralized health system. It is expected that the
provisioning of essential drugs at the public health service centres will create a demand
for other professional services from the local population, which, in turn, will boost the
general revival of activities in these service centres. In sum, this initiative under
NHP-2001 is launched in the belief that the creation of a beneficiary interest in the
public health system, will ensure a more effective supervision of the public health
personnel, through community monitoring, than has been achieved through the regular
administrative line of control.
4.4.2 Global experience has shown that the quality of public health services, as reflected
in the attainment of improved public health indices, is closely linked to the quantum and
quality of investment through public funding in the primary health sector. Box-V gives
statistics which show clearly that the standards of health are more a function of accurate
targeting of expenditure on the decentralised primary sector (as observed in China and
Sri Lanka), than a function of the aggregate health expenditure.
Box-V: Public Health Spending in select Countries
15 of 22
9/6/01 4:29 PM
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
1
%Population
with income of
<$1 day
Infant
Mortality
Rate/1000
%Health
Expenditure to
GDP
%Public
Expenditure
on Health to
Total Health
Expenditure
India
44.2
70
5.2
17.3
China
18.5
31
2.7
24.9
Sri Lanka
6.6
16
3
45.4
UK
6
5.8
96.9
USA
7
13.7
44.1
Indicator
Therefore, NHP-2001, while committing additional aggregate financial resources, places
strong reliance on the strengthening of the primary health structure, with which to attain
improved public health outcomes on an equitable basis. Further, it also recognizes the
practical need for levying reasonable user-charges for certain secondary and tertiary
public health care services, for those who can afford to pay.
4.5 EXTENDING PUBLIC HEALTH SERVICES
4.5.1 NHP-2001 envisages that, in the context of the availability and spread of allopathic
graduates in their jurisdiction, State Governments would consider the need for expanding
the pool of medical practitioners to include a cadre of licentiates of medical practice, as
also practitioners of Indian Systems of Medicine and Homoeopathy. Simple
services/procedures can be provided by such practitioners even outside their disciplines,
as part of the basic primary health services in under-served areas. Also, NHP-2001
envisages that the scope of use of paramedical manpower of allopathic disciplines, in a
prescribed functional area adjunct to their current functions, would also be examined for
meeting simple public health requirements. These extended areas of functioning of
different categories of medical manpower can be permitted, after adequate training and
subject to the monitoring of their performance through professional councils.
4.5.2 NHP-2001 also recognizes the need for States to simplify the recruitment
procedures and rules for contract employment in order to provide trained medical
manpower in under-served areas.
4.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS
4.6.1 NHP-2001 lays great emphasis upon the implementation of public health
programmes through local self Government institutions. The structure of the national
disease control programmes will have specific components for implementation through
such entities. The Policy urges all State Governments to consider decentralizing
implementation of the programmes to such Institutions by 2005. In order to achieve this,
financial incentives, over and above the resources allocated for disease control
programmes, will be provided by the Central Government.
16 of 22
9/6/01 4:29 PM
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
1
4.7 MEDICAL EDUCATION
4.7.1 In order to ameliorate the problems being faced on account of the uneven spread of
medical colleges in various parts of the country, NHP-2001, envisages the setting up of a
Medical Grants Commission for funding new .Government Medical Colleges in different
parts of the country. Also, the MedicaTGrants Commission is envisaged to fund the
upgradation of the existing Government Medical Colleges of the country, so as to ensure
an improved standard of medical education in the country.
4.7.2 To enable fresh graduates to effectively contribute to the providing of primary
health services, NHP-2001 identifies a significant need to modify the existing
curriculum. A need based, skill-oriented syllabus, with a more significant component of
practical training, would make fresh doctors useful immediately after graduation.
4.7.3 The policy emphasises the need to expose medical students, through the
undergraduate syllabus, to the emerging concerns for geriatric disorders, as also to the
cutting edge disciplines of contemporary medical research. The policy also envisages
that the creation of additional seats for post-graduate courses should reflect the need for
more manpower in the deficient specialities.
4.8 NEED FOR SPECIALISTS IN ‘PUBLIC HEALTH’ AND ‘FAMILY MEDICINE1
4.8.1 In order to alleviate the acute shortage of medical personnel with specialization in
‘public health’ and ‘family medicine’ disciplines, NHP-2001 envisages the progressive
implementation of mandatory norms to raise the proportion of postgraduate seats in
these discipline in medical training institutions, to reach a stage wherein 'A th of the seats
are earmarked for these disciplines. It is envisaged that in the sanctioning of
post-graduate seats in future, it shall be insisted upon that a certain reasonable number of
seats be allocated to 'public health’ and 'family medicine’ disciplines. Since, the 'public
health’ discipline has an interface with many other developmental sectors, specialization
in Public health may be encouraged not only for medical doctors but also for
non-medical graduates from the allied fields of public health engineering, microbiology
and other natural sciences.
4.9 URBAN HEALTH
4.9.1 NHP-2001, envisages the setting up of an organised urban primary health care
structure. Since the physical features of an urban setting are different from those in the
rural areas, the policy envisages the adoption of appropriate population norms for the
urban public health infrastructure. The structure conceived under NHP-2001 is a
two-tiered one: the primary centre is seen as the first-tier, covering a population of one
lakh, with a dispensary providing OPD facility and essential drugs to enable access to all
the national "health programmes; and a second-tier of the urban health organisation at the
level of the Government general Hospital, where reference is made from the primary
centre. The Policj^envisages that the funding for the urban primary health system will be
jointly home by the local self-Govemment institutions and State and Central
Governments.
17 of 22
9/6/01 4:29 PM
1
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
4.9.2 The National Health Policy also envisages the establishment of fully-equipped
‘hub-spoke’ trauma care networks in large urban agglomerations to reduce accident
mortality.
4.10 MENTAL HEALTH
4.10.1 NHP - 2001 envisages a network of decentralised mental health services for
ameliorating the more common categories of disorders. The programme outline for such
a disease would envisage diagnosis of common disorders by general duty medical staff
and prescription of common therapeutic drugs.
4.10.2 In regard to mental health institutions for in-door treatment of patients, the policy
envisages the upgrading of the physical infrastructure of such institutions at Central
Government expense so as to secure the human rights of this vulnerable segment of
society.
4.11 INFORMATION, EDUCATION AND COMMUNICATION
4.11.1 NHP-2001 envisages an IEC policy, which maximizes the dissemination of
information to those population groups, which cannot be effectively approached through
the mass media only. The focus would therefore, be on inter-personal communication of
information and reliance on folk and other traditional media. The IEC programme would
set specific targets for the association of PRIs/NGOs/Trusts in such activities. The
programme will also have the component of an annual evaluation of the performance of '
the non-Govemmental agencies to monitor the impact of the programmes on the targeted
groups. The Central/State Government initiative will also focus on the development of
modules for information dissemination in such population groups who normally, do not
benefit from the more common media forms.
4.11.2. NHP-2001 envisages priority to school health programmes aiming at preventive
health education, regular health check-ups and promotion of health seeking behaviour
among children. The school health programmes can gainfully adopt specially designed
modules in order to disseminate information relating to ‘health’ and ‘family life’. This is
expected to be the most cost-effective intervention as it improves the level of awareness,
not only of the extended family, but the future generation as well.
o
c<r
4.12 MEDICAL RESEARCH
4.12.1 NHP-2001 envisages the increase in Government-funded medical research to a
level of 1 percent of total health spending by 2005; and thereafter, up to 2 percent by
2010. Domestic medical research would be focused on new therapeutic drugs and
vaccines for tropical diseases, such as TB and Malaria, as also the Sub-types of
HIV/AIDS prevalent in the country. Research programmes taken up by the Government
in these priority areas would be conducted in a mission mode. Emphasis would also be
paid to time-bound applied research for developing operational applications. This would
ensure cost effective dissemination of existing / future therapeutic drugs/vaccines in the
general population. Private entrepreneurship will be encouraged in the field of medical
research for new molecules / vaccines.
4.13 ROLE OF THE PRIVATE SECTOR
18 of 22
9/6/01 4:29 PM
1
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
4.13.1 NHP-2001 envisages the enactment of suitable legislations for regulating
minimum infrastructure and quality standards by 2003, in clinical
establishments/medicaTinstitutions; also, statutory guidelines for the conduct of clinical
practice and delivery of medical services are to be developed over the same period. The
policy also encourages the setting up of private insurance instruments for increasing the
scope of the coverage of the secondary and tertiary sector under private health insurance
packages.
4.13.2 To capitalize on the comparative cost advantage enjoyed by domestic health
facilities in the secondary and tertiary sector, the policy will encourage the supply of
services to patients of foreign origin on payment. The rendering of such services on
payment in foreign exchange will be treated as ‘deemed exports’ and will be made
eligible for all fiscal incentives extended to export earnings.
4.13.3 NHP-2001 envisages the co-option of the non-governmental practitioners in the
national disease control programmes so as to ensure that standard treatment protocols are
followed in their day-to-day practice.
v
4.13.4 NHP-2001 recognizes the immense potential of use of infonnation technology
applications in the area of tele-medicine in the tertiary health care sector. The use of this
technical aid will greatly enhance the capacity for the professionals to pool their clinical
experience.
4.14 ROLE OF THE CIVIL SOCIETY
4.14.1 NHP-2001 recognizes the significant contribution made by NGOs and other
institutions of the civil society in making available health services to the community. In
order to utilize on an increasing scale, their high motivational skills, NHP-2001
envisages that the disease control programmes should earmark a definite portion of the
budget in respect of identified programme components, to be exclusively implemented
through these institutions.
4.15 NATIONAL DISEASE SURVEILLANCE NETWORK
.
'
4.15.1 NHP-2001 envisages the full operationalization of an integrated disease control
network from the lowest rung of public health administration to the Central Government,
by 2005. The programme for setting up this network will include components relating to
'nsta^atlon °f data-base handling hardware; IT inter-connectivity between different tiers
/ of the networkfand, in-house training for data collection and interpretation for'.
undertaking timely and effective response.
4.16 HEALTH STATISTICS
4.16.1 NHP-2001 envisages the completion of baseline estimates for the incidence of the
common diseases - TB, Malaria, Blindness - by 2005. The Policy proposes that
statistical methods be put in place to enable the periodic updating of these baseline
estimates through representative sampling, under an appropriate statistical methodology.
The policy also recognizes the need to establish in a longer time frame, baseline
estimates for : the non-communicable diseases, like CVD, Cancer, Diabetes; accidental
19 of 22
9/6/01 4:29 PM
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
1
injuries; and other communicable diseases, like Hepatitis and JE. NHP-2001 envisages
that, with access to such reliable data on the incidence of various diseases, the public
health system would move closer to the objective of evidence-based policy making.
4.16.2 In an attempt at consolidating the data base and graduating from a mere
estimation of annual health expenditure, NHP-2001 emphasis on the needs to establish
national health accounts, conforming to the 'source-to-users’ matrix structure. Improved
and comprehensive information through national health accounts and accounting
systems would pave the way for decision makers to focus on relative priorities, keeping
in view the limited financial resources in the health sector.
4.17 WOMENS HEALTH
4.17.1 NHP-2001 envisages the identification of specific programmes targeted at
women’s health. The policy notes that women, along with other under privileged groups
are significantly handicapped due to a disproportionately low access to health care. The
various Policy recommendations of NHP-2001, in regard to the expansion of primary
health sector infrastructure, will facilitate the increased access of women to basic health
care. NHP-2001 commits the highest priority of the Central Government to the funding
of the identified programmes~relatmg to woman’s health. Also, the policy recognizes the
need to review the_suiTfing norms of the public health administration to more
comprehensively meet the specific requirements of women.
4.18 MEDICAL ETHICS
4.18.1 NHP - 2001 envisages that, in order to ensurethat the common patient is not
subjected to irrational or profit-driven medical regimens, a contemporary code of ethics
be notified and rigorously implemented by the Medical Council of India.
4.18.2 NHP - 2001 does not offer any policy prescription at this stage relating to ethics
in the conduct of medical research. By and large medical research within the country is
limited in these frontier disciplines of gene manipulation and stem cell research.
However, the policy recognises that a vigilant watch will have to be kept so that
appropriate guidelines and statutory provisions are put in place when medical research in
the country reaches the stage to make such issues relevant.
4.19 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DRUGS
4.19.1 NHP - 2001 envisages that the food and drug administration will be progressively
strengthened, both in terms of laboratory facilities and technical expertise. Also, the
policy envisages that the standards of food items will be progressively tightened at a
pace which will permit domestic food handling / manufacturing facilities to undertake
the necessary upgradation of technology so as not to be shut out of this production
sector. The policy envisages that, ultimately food standards will be close, if not
equivalent, to codex specifications; and drug standards will be at par with the most
rigorous ones adopted elsewhere.
4.20 REGULATION OF STANDARDS IN PARAMEDICAL DISCIPLINES
4.20.1 NHP-2001 recognises the need for the establishment of statutory professional
20 of 22
9/6/01 4:29 PM
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
councils for paramedical disciplines to register practitioners, maintain standards of
training, as well as to monitor their performance.
4.21 OCCUPATIONAL HEALTH
c I
4.21.1 NHP-2001 envisages the periodic screening of the health conditions of the
workers, particularly for high risk health disorders associated with their occupation.
4.22 PROVIDING MEDICAL FACILITIES TO USERS FROM OVERSEAS
4.22.1 NHP-2001 strongly encourages the providing of health services on a commercial
basis to service seekers from overseas. The providers of such services to patients from
overseas will be encouraged by extending to their earnings in foreign exchange, all fiscal
incentives available to other exporters of goods and services.
4.23 IMPACT OF GLOBALISATION ON THE HEALTH SECTOR
4.23.1 NHP-2001 takes into account the serious apprehension expressed by several
health experts, of the possible threat to the health security, in the post TRIPS era, as a
result of a sharp increase in the prices of drugs and vaccines. To protect the citizens of
the country from such a threat, NHP-2001 envisages a national patent regime for the
future which, while being consistent with TRIPS, avails of all opportunities to secure for
the country, under its patent laws, affordable access to the latest medical and other
therapeutic discoveries. The Policy also sets out that the Government will bring to bear
its full influence in all international fora - UN, WHO, WTO, etc. - to secure
commitments on the part of the Nations of the Globe, to lighten the restrictive features of
TRIPS in its application to the health care sector.
5. SUMMATION
5.1 The crafting of a National Health Policy is a rare occasion in public affairs when it
would be legitimate, indeed valuable, to allow our dreams to mingle with our
understanding of ground realities. Based purely on the clinical facts defining the current
status of the health sector, we would have arrived at a certain policy formulation; but,
buoyed by our dreams, we have ventured slightly beyond that in the shape of NHP-2001
which, in fact, defines a vision for the future.
5.2 The health needs of the country are enormous and the financial resources and
managerial capacity available to meet it, even on the most optimistic projections, fall
somewhat short. In this situation, NHP-2001 has had to make hard choices between
various priorities and operational options. NHP-2001 does not claim to be a road-map
for meeting all the health needs of the populace of the country. Further, it has to be
recognized that such health needs are also dynamic as threats in the area of public health
keep changing over time. The Policy, while being holistic, undertakes the necessary risk
of recommending differing emphasis on different policy components. Broadly speaking,
NHP - 2001 focuses on the need for enhanced funding and an organizational
restructuring of the national public health initiatives in order to facilitate more equitable
access to the health facilities. Also, the policy is focused on those diseases which are
principally contributing to the disease burden - TBj’Malaria and Blindness from the
category of historical diseases; and HIV/AIDS from the category of ‘newly emerging
21 of22
9/6/01 4:29 PM
1
file:///D|/EMAIL RECEIVED/nationalhealthpolic.htm
*
diseases’. This is not to say that other items contributing to the disease burden of the
country will be ignored; but only that, resources as also the principal focus of the public
health administration, will recognize certain relative priorities.
«
5.3 One nagging imperative, which has influenced every aspect of NHP-2001, is the
need to ensure that ‘equity’ in the health sector stands as an independent goal. In any
future evaluation of its success or failure, NHP-2001 would like to be measured against
this equity norm, rather than any other aggregated financial norm for the health sector.
Consistent with the primacy given to ‘equity’, a marked emphasis has been provided in
the policy for expanding and improving the primary health facilities, including the new
concept of provisioning of essential drugs through Central funding. The Policy also
commits the Central Government to increased under-writing of the resources for meeting
the minimum health needs of the citizenry. Thus, the Policy attempts to provide
guidance for prioritizing expenditure, thereby, facilitating rational resource allocation.
5.4 NHP-2001 highlights the expected roles of different participating group in the health
sector. Further, it recognizes the fact that, despite all that may be guaranteed by the
Central Government for assisting public health programmes, public health services
would actually need to be delivered by the State administration, NGOs and other
institutions of civil society. The attainment of improved health indices would be
significantly dependent on population stabilisation, as also on complementary efforts
from other areas of the social sectors - like improved drinking water supply, basic
sanitation, minimum nutrition, etc. - to ensure that the exposure of the populace to health
risks is minimized.
Suggestions on the draft policy are welcome. Kindly mail your suggestions to aeabop@nb.nic.in within
30 days.
22 of 22
9/6/01 4:29 PM
I
Greetings
Subject: Greetings
Date: Wed. 19 Sep 2001 16:43:48 +0530
From: Community health cell <sochara@vsnl.com>
To: vhai^vsnl.com
3■a
1
Dear Alok,
Greetings from Community Health Cell'
1 just returnea after a day in Indore assessing how CHC*s second review
of the JSR Scheme in MP is orogressinq and also after two davs in Mumbai
attend-’ng the Nationa1 Coordination Committee T^Jjpting of Jana Swasthya
’ibhiyan whore wo had among other agenda a vary rn, depth discussion on .j...,
the National Health Policy. I received your latter and email inviting
me teethe Round Table on NHP. Thanks but due to prior commitments I
cannot"’join in. Perhaus Thelma may agree since she has completed an
integrated Health Nutrition and Population.Poli'^y.'- .a ''draft which has
now been circulated by the. Director of Health-S^yl.ces., for comment
before it goes for approval to the legislature. ; She is busy with the
HNP Project - Sequel to Karnataka Task Force so do write to her if
you would think it is a good idea.
With best wishes.
j
Dr. P.avi Narayan
PS;There was a typographical error in the message sent at 2.17 pm.4 The
errors have been corrected in this message.
■^A
1 of 1
9/19/01 4:48 F
T!yP-33004/99
REGO. NO. D. L.-33004/99
oFH
(the (Baxette of (Sudia
3^WTTPir
EXTRAORDINARY
HPT n—3 —HR-T^rg- (jj)
PART II—Section 3—Sub-section (ii)
TUf^nR it Ucblf^ld
PUBLISHED BY AUTHORITY
10, 2001/3tlMI<o 19, 1923
(Xr41,
U 466]
No. 466]
NEW DELHI, TUESDAY, JULY 10, 2001/ASADHA 19,1923
■w^r aft? mRcjh ch^iui
Red), 10
affr mR^H che4Nl qRq^^r
4r^hT
cST. 3TT. 6S6 ( 3T).—WA
31k iTRvf
2001
7TW5T SbHIEIR^F WT 2,
ihlcPI
srf^RJxRT
4>^q ^c||7e4
3,
TTf^tR
£ ^TcH
tts^t 3flY
aft? yfsb'UI
MO’^rr
1.
4lcH
(I)
Rnfcifecr
PidcR
41 Vi’I I 3il4Vl
H f^EIFPfecft
cHet >Uv4T
4l<3d cb'fct t? 3iR 5^1
STtokf
gRl fcF’V "STFi ^11 c-1
—
3TOTJ
4>’41^ \!|v4q4t
;?Tv^r
qf^R ctxSTPT, RjORTT f^TT 3ft?
3ft?
*131 cl41
4> OTI^t O
c[ ^rrn? ^4cft, 44) ■‘i^ srrft 3ft? A<41^1?
w?
2151 GI/2001
s^ta 3ft?
>l0lRld
‘R^lRlvf QWcl 1?t,, ST^IRT
Pi^f^RsRi w 3 L^TPuftd
sr^ -
(^7)
?W^ 3ft? MRdT? cbc^RI
(V?) ?c| i^kj aft? M Rd I v cbc^id *13 M 4
(^)
(i i), dlfl'U 6 3I^H,1999
^.16011/1/98-^.^., arfta 6 ST^eT, 1999
qR<tf<
wif cf5t jr^r
SPit’T
3T^fe' 263 W 5Rvl ^rf^'
w W mAAA’
0)
?i^
^T^T
THE GAZETTE OF INDIA : EXTRAORDINARY
2
[Part II—Sec. 3 (ii)]
(r()
1. ^TO
SFfiK vlHH1<4lci
(sW)
2.
^FHi
3. ^10
XFHT
4. ^TO (^ft)
(^)
sfty mR4R
(1)
^2J^,
1/
yfclPrf^
811^(3 Si FT
(q^O
3I^Wr ^Kcfl4 mR^R
3rew, ^1^4
<1*041 °F hR^4
2.
3.
^7)
SJE^I, ^4 4HF4 0<?4W
3JEW,
4.
5.
41^4 SR^RsIFT ^^14 4RR4 4<
6.
n n , k!
(
(4^f)
3IS4ST, Slfeel 4T^ft4 fMt44T 44, Hf Rcvft (4^4)
7.
(H)
1.
f^T, snt^
J!X yitwn^ whra®
WTtf EH^t H^T, WT^t
'
.p
v
2.
■ ”“4 •
3
4
5fto -4t
6 J
TJ^, ■»ja^ pW<R3Te^?n^,v
f^nw.
cpT^r T^g srwaief, f^Ffi
8.
%TZS-^ '
3
[^7 11—7^3(11)]
(vT)
SFTWT
rRr[,^IRR fftRTRRRRR sfR qRcIK ^eRFR HRTcTR
1.
2.
rRr,rR^R ^eRRT fftHTR, ^RTRR afR mP<4H ^dRTR 4^101^
ftRFR ,'FdT.
dPN^Ral^ Rrf^eRT M<&R1 RA
3
'dd'W
qRaix cheui dl ^Pdei^
rRfrRiRT, fftRTRRFR rR|£|R PcblR HRTRR
RpF 4f df^dl dRT RFR R<PlR R d HI
4.
5.
6.
Ar (^) (II) $ R^JT 1
R^R
I cfeW
fcR M^ct
( iii)
f ■33FT cfr
W
8 d^> R<^ld cilRvT RTRRRdRT dF W ^t 3TRRF
R^RI, U«r
R^W ^PT Ref W A RT eft
Bf i
fcR Rf
( iV )
RRF ft^ RURT dH d<t> dR^d
t STRcH 9 ^cll£,2003 dH> Rt ftt
I
(v)
(V)
qR^r<
STR-190 cfr
^RF
RdRT VeR RW d^ 3 7RJT ^PTT c&
^-^rwr^t
<& ^t^tf
-Hr;
W HRH ^R^R ^RF WF> sMfa RHR-^rpT tR
fc^ Sii^i) <£
wf cT^
ST^EFR RPl^4Rd fcplj rtJR |
RR R? ’^ft RFeft W7 eftt TjfiS ^R RRRFT
(Vi)
vfT^rft I
Wd 3TJHFF 4
feR
cf>^l<4 R<cbR sfR RXiR ti^chl^t
dRT deh4|cftt ReTT^TR
^FT S[R MRtfR gTR pRfa foR Rift RHR R% HU
<R GTpT^R
(yij )
RRRT
R^ uR qRqu sftr srftRd
eft ft mR^k
ftunft ft ^fRr ^rft I
R rRRUf cbJpdlRcK ^PlT RRPt
(viii)
^PT Rrad STEzra,
2.
nft^R SRT
qfaK
twcbR c£ sjyiWf
dlRld 614ll d^TF \3d^ STpl^Pl sftv
Pl^/w cR^FT \3Rld TERRI I
M<£pF -
vTT^
RRR^R p|cbl4
R
^HT I
sfk
tftPRT
PT^lfclPski
c|5^ft,
sretfa (^)
TRTRR R4 mR<1R ^eRTR eft
A RRRlR R^t Hgcgsft ^R 41 pF Ht^t-414t
Rq^T *R fftRR-fftR^ RRT RwtRr 3RR uRt - RW^ 'NlWIcffe sfR VtR
THE GAZETTE OF INDIA : EXTRAORDINARY
-----^T^ft
■
[Pakt 11 jgg—
~ZZ LvrafihTK TTCFre w ttrsi ftisn afk Rftrspi
4^41, WNXNI^
J*
1
sfR
w nf^R^T *
a?n
^thih srf^ra^ra'
1
<&
3MTRHT 3hR-^^
f^r 3
hsr
f^rRr n <znxre> otejr <rc ^®n
3-fR TITHHI qiT^T ^R
1
sfR^OTT 5RWi *
Ga-)
afkiM^
w^tRT
Tl^rai 3^
isY r» .S“-- - ---^tfS I
* fav M* »«™
TRH3
qiH-Tt-^H
Ppth f^Rn ^t^tt I
*? wft tos * ftK! ira WfRfi (3i™ ^) '6I
1
(h)
tra .(i) * as (s) « Wre ’asw> 3 s™ s™
(O
qftqcf q^r tw 3 Wr
(3T£2r«T ^a)
na gW I
5R^
$ f^n ^rni 1
fit5® *t«
cpl fjJplW1! ^3^ ’i vjMR^r^
5
[HFTII—3(ii)]
(B)
^-16011/2/2001-^tA]
'eft. SIR. 3RTR TTR, 3W ■uFmci
MINISTRY OF HEALTH AND FAMILY WELFARE
NOTIFICATION
New Delhi, the 10th July, 2001
Constitution of Central Council of Health and Family Welfare
S.0.656(E).—in exercise of the powers conferred by the
Article 263 of the Constitution and in supersession of this
Ministry's notification No.Z.16011/1/98-B.P., dated 6th April,
1999 published in the Gazette of India : Extraordinary Part - II
Section 3 Sub-Section (ii) dated 6th April, 1999, the President
hereby constitutes the Central Council
of Health and Family
Welfare and defines the nature of duties to be performed by it
and its organisation and procedure as follows. namely :-
1.
Organisation of the Council:
(i)
The Council shall consist of
for Health
Chairman
(a)
The Union Minister
and Family Welfare
(b)
The Union Minister of State
in the Ministry of Health
and Family Welfare
ViceChairman
(c)
Member, Planning Commission
Member
(d)
Ministers in charge of the
:
Ministries of the Health and
Family Welfare, Medical Education
and public Health in the States/
Union Territories with Legislatures.
Members
THE GAZETTE OF INDIA : EXTRAORDINARY
6
[Part II—Sec. 3(ii)]
(e)
A representative each of the
Dadar Nagar Haveli, Chandigarh,
Andaman and Nicobar Islands,
Daman and Diu and Lakshadweep
Members
(f)
Members of Parliament:
Members
(g)
1.
Dr. Madan Prasad Jaiswal
2.
Dr.
3.
Dr. A.K.Patel
4.
Dr.
(Smt.) C.Suguna Kumari
(Ms) P.Selvi Das
Lok Sabha
Lok Sabha
Rajya Sabha
Rajya Sabha
No n-Officia1s:
Members
(i)
Representatives from Health
and Family Welfare Sectors
1.
President, Indian Medical Association
(ex-officio)
2
President, Family Planning Association of
India, Bombay, (ex-officio)
3.
President, Indian Council of Child Welfare,
New Delhi. (ex-officio)
4.
Chairperson, Central Social Welfare Board,
New Delhi, (ex-officio)
5.
The President, Federation of Indian Chambers
of Commerce and Industry, New Delhi.
(ex-officio)
6.
Director General, Indian Council of Medical
Research, New Delhi, (ex-officio)
7.
The President, All India Organisation of
Employers, New Delhi (ex-officio)
(ii) Eminent Individuals:
1.
Vaidya Devendra Triguna, Ayurvedic Physician,
General Secretary, All India Ayurvedic Congress,
Dhanwantri Bhawan, Punjabi Bagh, New Delhi.
2.
Shri
Alok
Mukhopadhyay,
Chief
Executive,
Voluntary Health Association of India, Tong
Swasthya Bhawan, 40 Institutional Area, South of
IIT, New Delhi-110016
7
[HFTII—3(ii)]
3.
Prof. Alokendu Chatterjee, Ex President. The
Federation
of
Obstetric
&
Gynaecological
Societies of India (BA-49, 1st Avenue, Sector-1,
Salt Lake City, Calcutta - 700064.
4.
Prof. D.D.Guru, former Professor of Economics,
A.N.Sinha Institute, Patna.
5.
Dr. Ganesh Rane,
Rotary International, Mumbai.
6.
Da..
Head, Deptt. of
Dr. S.K.Sarin, Professor and
Gastroenterology, G.B.Pant Hospital, New Delhi.
7.
Prof.
K.
Mathangi
Ramakrishnan,
former
Chairperson and Professor of Plastic Surgery at
Kilpauk Medical Cqllege and Hospital, Chennai.
8.
Mrs. Rose Millian Bathew (Kharbuli), former
Chairman, Union Public Service Commission.
Officials:
(h)
• 1.
Secretary, Department of Health
Ministry of Health & Family
Welfare
Member
2.
Secretary, Department of Family
Welfare, Ministry of Health &
.Family Welfare
Member
3.
Secretary, Department of Indian
Systems of Medicine & Homoeopathy
Ministry of Health & Family Welfare
Member
4.
Secretary, Department of Education :
Ministry of Human Resource
Development
Member
5.
Secretary, Department of Women and :
Child Development
Member
6.
Director General of Health Services:
Member
7.
Deputy Director General of Health
Services (Pig. )
Member
Secretary
(iii)
Eminent individuals at (g) (ii) 1 to 8 shall normally
be members of the Council for a period of two years,
The Members of Lok Sabha shall be Members of the
Council so long as they are members of Lok Sabha or
two years whichever is earlier.
8
THE GAZETTE OF INDIA : EXTRAORDINARY
[Part II—Sec. 3(ii)]
The Members of Rajya Sabha shall be Members of the
(iv)
Council so long as they are members of Rajya Sabha, or
till 9th July, 2003 whichever is earlier.
The
(v)
travelling
and
allowances
daily
of
the
non-
official members for attending the meetings of the
Council shall be regulated in accordance with the
provision of Supplementary Rule 190 and orders of the
Government of India thereunder as issued from time to
time.
4
(Vi)
The expenditure involved will be met from within the
sanctioned budget grant for the purpose.
(Vii)
Expert
technical
and
advisers
to
the
Central
Government and State Governments shall not be members
of the Council and shall not have any right to vote
when any decision is taken by it but shall, if so
required by the Council,
be
in
attendance
at
its
meetings.
(viii)
The Council shall have a Secretarial staff consisting
of a Secretary and such officers and officials as the
Chairman
may,
with
the
approval
of
the
Central
Government, think fit to appoint.
2.
Nature of the duties to be performed by the Council:
The Council shall be an advisory body and in that capacity
shall perform the following duties, namely:(a)
to consider and recommend broad lines of policy in
regard to matters concerning Health and Family Welfare
in all its aspects, such as the provision of remedial,
promotive and preventive care, environmental hygiene,
nutrition,
health
education
and
the
facilities for training and research;
promotion
of
9
[HFT II—3(ii)l
in fields of activity
to make proposal for legislation
public health and Family
relating to medical and
down
the
pattern
of
matters,
laying
Welfare
a whole;
development for the country as
(b)
to examine the whole field of possible co-operation
a wide basis
basis in regard to inter-state quarantine
during times
times of
of festivals
festivals,, out-break of epidemics an
serious calamities
ealamitres such
such as
as earth-quakes and famines
(c)
programme or action.
and to draw up a common nroaramme
(d)
to make recommendations to the Central Gcvernm
regarding distribution o'i available grants-m-aid for
Health and Family welfare purposes to the states an
to review periodically the work accomplished in
different areas
through the utilisation of these
grants-in-aid; and
(e)
3.
organisation or organisations
to establish any
functions foi promoting and
invested with appropriate
maintaining co-operation between the Central and State
Welfare administration.
Health and Family
Procedure of Xbe__£ounciL—
The Council shall in its
following procedures, namely:-
(a)
conduct
of
business
observe
in every year;
the Council shall meet at least once
(b)
as the Chairman
it shall meet at such time and place
may appoint in this behalf;
(c)
the Chairman) shall form the
five members (including
quorum for a meeting of the Council;
10
{Part II—Sec. 3(ii)|
(<J)
1 he chairman and, in his absence vice-chai
airman^ vice-chairperson Or such member as may
to in
w
Xby *
(f)
m case of equally of votes, the person presiding shall have a second or casting vote;
(g)
the Council shall observe i
lhe approva! of .he
"eXSZ
±Z°“dUre “ “
'vernment, lay down from time to time.
[No. Z-16011/2/2001-B.P.J
J.VR. PRASAD A RAO, Addl. Secy.
Prin^ by the Manager Govt of India Press, Ring Road, Mayapuri, New Delhi-110064
Controls of Publications, Delhi-110054.—2001.
and Published by the Controller
1
DRAFT NATIONAL HEALTH POLICY-2001, A CRITIQUE
by
Dr. N. S. Deodhar, Health Consultant, Pune
FRLUMIN/XRY REMARKS:
To open the debate, the draft policy statement, apart from being unintelligible,
giving misleading statistics, needing prose editing, etc., will not take the nation on the
path of health. Many statements are not substantiated. Information given under the
heading of present sceniaro, in many instances, has no relevance to the answers in
NHP-2001. In marked contrast with its neglect, term ‘public health’ is used generously.
However, nothing can be achieved just by suffixing the word ‘public’ to health. The
important terms such as public health and primary health care are not defined, and even
understood. A simple diagram summarizes the epidemiological status of the proposed
national health policy. The draft is a death notice to public health and cannot be
approved.
Diagram I: irrationality of the proposed National Health Policy
Pratt
[
National
Health
Policy
/
Health tatus
Health Services with
ft Associated Health Care
4
■.......................... ..............................■■■■
'
/ v. -.
'
■■■■■'-■
ft
4
A
/
:=Vy.
Poor Environmental / \)
Sanitation
/ /
W
Unhealthy
Lifestyles .
B
A
Morbid Public
.. ......
—
■- \ Health System
---------(Concept, idea and design by NSD)
S
E
2
—
A note for a Round-Table organized by the ICHI at New Delhi on 26-27 September 2001.
1. INTRODUCTORY:
1.1
Many aspects of the National Health Policy-1983 (NHP-1983) are still valid.
However, it suffered from contradiction between its profession and practice from very
inception. In view of this, it is necessary to ensure that NHP-2001 will not end in
nemesis. It is desirable that the new policy should come as a legislative act and not just a
statement. Non-observance should be open for judicial case and punishable.
1.2
Many noteworthy initiatives of the NHP-1983 are valid even today. Apart from
the four mentioned in the draft, there are more important items that deserve mention, e.g.,
the main thrust of 1983 policy was the Nation’s commitment to provide universal access
to basic health facilities through primary health care approach. This and other unfinished agenda cannot be allowed to lapse un-met.
1.3
This section records some noteworthy successes. However, the major events such
as eradication of smallpox and stabilization of malaria to 2-3 million cases took place
even before NHP-1983. Physical infrastructure has increased, but data on its
performance is not given. It is common knowledge that the system is not functioning
satisfactorily, people are not happy and has failed to reduce morbidity.
National health policy has to be formulated only on the basis of sound data and
information. Unless the developments since NHP-83 are correctly assessed, it will not
be possible to have necessary data-base which is relevant, appropriate, and valid for
formulating NHP-2001. Such data should cover the period between 1983 and the latest
available information, together with the targets which were set for year 2000, as
applicable. Therefore, we should gather the following data and information. The selected
indicators should provide both the situation and impact in the areas such as:
(a) Demography (life expectancy, death and birth rate, IMR, MMR, sex ratio, fertility, &
percentage of children below 16 yr, etc.).
(b) Morbidity and mortality data on communicable and non-communicable diseases
(Tuberculosis, malaria, leprosy, filariasis, dengue fever, diarrhoea in children <5 year,
acute respiratory infection in children <5 year, sexually transmitted diseases including
HIV/AIDS, cholera, hepatitis, diabetes, cardio-vascuiar diseases, cancer, etc.)
(c) Data on environment (water supply, sanitation, excreta disposal, pollution, safety,
etc.)
(d) Nutrition security (average birth weights, child mortality 1-5 year, prematurity rate,
prevalence of anemia & other nutritional deficiency disorders, malnutrition, BMI, etc.)
(e) Lifestyle data (Status of women, development index, occupation, fiscal status, etc.)
(f) Health services data (Institutions, manpower, facilities, programmes, management,)
It is essential to provide data on performance programme-wise, financial,
management
3
and other information which is covered in the annual reports for the period 19832001.
1.4
As mentioned in this section, our gains are largely due to the so-called non-health
interventions and programmes. This was in spite of poor performance of public health
care and largely due to the developments in other sectors and better socio-economic
conditions. .
This statement acknowledges our overall failure to control communicable diseases
1.5
in tiie past two decades or more. Further, the load of non-communicable or lifestyle
diseases will be on increase. Public health system is so weak that it is unable to contain
epidemics promptly, leave alone preventing recurrences. This situation needs very
serious consideration and newer strategies. We cannot go on the beaten path, a path of
failures.
1.6
This section is only a statement of intent and no more.
2.0 CURRENT SCENARIO:
Most of the items which were included under this section are considered later in
conjuction with the corresponding item of the new policy. However, three most
important items which are included in this section, but are not covered under NHP-2001,
have been examined and are presented below:
2.24 NON-HEALTH DETERMINANTS
The draft states that NHP-2001 will not explicitly address itself so-called non
health determinants. This is outrageous and total reversal from the National Health
Policy 1983. The main thrust of 1983 policy was the Nation’s commitment to provide
universal access to basic health facilities through primary health care approach. It
stressed the need to link health services with health related activities in other
development areas such as nutrition security, drinking water, and sanitation1 and
environmental health. In such a case, there is no need for any health policy.
National health policy cannot be the restricted to a single ministry because health
is all pervasive. The so-called ministry of health is really a ministry of “ill-health”
because it gives only curative care to the sick and very little of public health. The basic
determinants of health are nutrition, environment and lifestyle. In all these Health and
Family Welfare Ministry plays only a minor role. The so-called non-health determinants
are true pillars of health. Scientifically, drafting the National Health Policy should be a
joint exercise of all the major ministries and departments concerned. In brief, the ‘nonhealth determinants’ should form an integral part of NHP-2001 even if they fall outside
the domain of the Ministry of Health and Family Welfare.
2.25 POPULATION GROWTH AND HEALTH STANDARDS
4
Statement that the efforts for improving health standards have been neutralized by
rapid growth of population is not the full reality. A major component is the poor
management of what we had and have. We have wasted resources and certainly not used
them judiciously and optimally. It is also essential to strictly implement national
population policy. We have to shift from contraceptives to development. We have to
satisfy all kinds of un-met needs comprehensively in an integrated manner. It will be
disastrous, if any one thinks just of meeting the un-met needs of contraceptive services.
2.26 ALTERNATIVE SYSTEMS OF MEDICINE
It is high time to have self-esteem. When we are going to discard use of the
western terms which are inappropriate to ourselves? Ayurveda is ours and cannot be an
alternative to us as for the non-Indians. We should talk of pleuristic or complimentary
systems of medicine. ‘We seem to be ignorant of our strengths. We equate Ayurveda to
herbal medicines, forgetting that it is a science of longevity. It has the yoga and lifestyle
prescriptions for health promotion and much beyond spiritually. Let us think high and act
gracefully with faith in oneself an dignity.
3.0 OBJECTIVES OF NHP-2001
These should have been more explicit, viz. (a) to strengthen public health system
so as to ensure efficiency and effectiveness of public health practice and programme, and
(b) to raise the standard of health of the people through satisfactory case of all the sick;
prevention of diseases and disabilities through environmental health and other public
health measures; and health promotion by promoting healthy lifestyles, occupational
health, pollution control and enrichment of environment, etc.
It is necessary to identify appropriate indicators to monitor these objectives, rather
that selecting the indicators as provided in Box-IV. These indicators should be
essentially for assessment of the impact. Objective of the policy cannot be like increasing
the health expenditure. More important is what do we do with the money.
It is not clear as to how the goals and the time-frame to achieve them are arrived
al. what interventions and methods are expected to bring about the change and the
impact? We have failed to reach the targets set for year 2000. Are we planning to extend
them, as we have done in the case of population control?
4. NHP-2001 - POLICY PRESCRIPTIONS
The terms primary health care and public health are used loosely without having
insight into its real meaning. The real interpretation is provided in the recommendations.
5
4.1 FINANCIAL RESOURCES
Currrent scenario regarding financial resources is given in ssection 2.1 brings out
the issue of paucity of funds. Further, it makes a plea that unless States are funded by the
Central Government, they will not be able to take their constitutional responsibility for
public health. Such an approach will make the States dependent on the Centre and this is
not desirable. What is needed is to open out new financial resources to the States,
provide them a larger share of the taxes they collect, and have better financial
management.
However, the main point is that expenditures on health are not considered as
investment. Limited funds are not judiciously spent.
Cost-effectiveness of the
expenditures is never heeded. Because of wrong priorities, limited financial resources are
spent wrongly. Neither are the priorities determined scientifically nor the resources
allocated according to the need. Funds at disposal are neither fully utilized nor used costeffectively. There are distortions. Disproportionately larger funds are provided for
curative services and tertiary medical care. This is despite the fact that tertiary health
care is very costly, highly technical and calls for sophisticated intervention, cost
effectiveness is low and benefits only few in urban areas. Further, this practice results in
the neglect and poor funding of crucial and cost-effective primary health care to the
common people. Expenditure on medical education for training MBBS and specialist
doctors is extravagant as compared to that incurred on training and capacity building of
all other categories of staff such as nursing, paramedical and field workers. State
expenditures, from the State funds, on the preventive and promotive health care are
negligible, if any. If the central assistance is inadequate for implementing the national
health programmes, the State fails to supplement the shortfalls. The Government of
India provides funds for appointing ANMs. The State Government has to provide for the
posts of Male Health Workers.
Provision in NHP-2001 is to increase the health expenditures to six per cent of
GDP by the Central Government and the State Governments to spend on health, seven
per cent of the total budget. It also proposes to raise Central Government’s contribution
to the State Plans from the current level of 15 per cent to 25 per cent by year 2010. Basis
of these estimates is not provided.
4.2 EQUITY
Section 2.2.1 provides statistics which highlight the regional, interstate, and
gender differences, disparities and imbalances. However, information on malaria is the
number of reported cases of malaria. This information is not suitable for interstate
comparison. It is essential to convert the data into prevalence rates. Section 2.2.2 ia
about the access to the facilities to different socio-economic groups. This has happened
despite the developmental policy of equitable distribution, development and access. It
correctly states that the national averages hide these disparities. However, the data
6
presented in Box-Ill is not at all valid for the purpose and inference drawn is wrong.
Indicators for accessibility are quite different. Incidentally, the quality and reputation of
health services is so low that even the poor do not avail them. The factor of accessibility
does not operate. The observed differences in the mortality and nutritional data, are due
to epidemiological reasons. Castes and tribes are essentially a confounding factor; real
determinants are factors such as poverty, lifestyle, poor health related knowledge, etc.
Data which .clearly brings out lack of equity are presented in Table 1.
4
New policy hopes to reduce inequalities and improve access. To serve the
purpose of inter-regional and other imbalances and disparities, NHP-2001 envisages to
allocate 55 per cent of the total public health expenditure, for the primary health care, 35
per cent to the secondary health care, and 10 per cent to tertiary health care. Here it is
essential to clarify what is meant by public health. It is not clear whether the total health
budget is the gross amount or the net amount or crumbs left after deduction of the budget
provisions for curative services, educational and national institutes, research, etc. While
this break-up is appreciated, further break down criteria are required to ensure more
equitable distribution of the available funds.
Table 1: India 1992-93, Health, Nutrition and Population
by Socio-economic Status
(Sample size = 5,00,755)
Socio-economic Status
Indicator
Poorest
IMR/1000 births
109.2
Richest
Average
86 3
4<0
U5MR/1000 births
154.7
54.3
118.8
Total Fertility Rate
4.1
2.1
3.4
Age Specific Fertility Rate
per 1000 women, (15-19 yr.)
135
4^
115
mmunization Coverage
- For all vaccines, %
- Not immunized at all, %
Delivery Attended by a
Trained Person, %
Use of Contraceptives by
17.1
48.4
11.9
65.0
35.4
5.9
3( .0
78 7
3<3
7
Married Women, %
24.9
50.6
36.5
Source : Country Reports on Health, Nutrition, Population Status and Service Use among
Poor and Rich, World Bank, HNP, May 2000.
Note: IMR
Infant Mortality Rate. U5MR = Under Five Mortality Rate (of children)
The following are the criteria suggested for further break down to ensure more
equitable distribution of the available funds:
Of the 55 per cent share for primary health care, at least half should go for fon''lie<
below poverty line.
• District hospitals should be included in the
35 per
per cent
cent share
for the
secondary health
health
the 35
share for
the secondary
care, and five per cent should be spent on the preventive and promotive component of
the medical care, e.g., counselling.
• Medical college hospitals should be included in 1the 10 per cent share for the tertiary
health care, and five per cent should be spentt on the preventive and promotive
component of the medical care, e.g., counselling.
• Appropriate number (10-15 %) of the secondary and tertiary care hospital beds must
be reserved for free/state-supported treatment to the persons below the poverty line.
• Of the overall health budget, 40 per cent to go for curative services and 60 per cent
for the preventive and promotive health care.
• Of the overall health budget, 30 per cent to go for urban areas and 70 per cent for the
rural areas. Of the rural share, at least half should go for families below poverty line.
• Of the central assistance to the States, 70 per cent share should go to the PRIs
directly, and 30 per cent to the health directorate for training of non-medical health
personnel. The central assistance to the States should be conditional to ensure that the
states meet the basic requirements and their own responsibilities from their own
resources, etc.
• Purely Central schemes should be for the purposes of union territories, national
institutions, national schools of public health in different regions and research.
• Entire international and bilateral funding for health should be only for establishing
educational and training health institutions and centres such as schools of public
health, other aspects of institutional building such as modem equipment and research,
manpower development through short and long term travel and training fellowships,’
etc. No funding for any specific disease control programme, etc., should be accepted.
•
4.3 DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
Section 2.3 recognizes the need for flexibility of the national health programmes
and allowing the States to formulate their own programmes. It also talks of progressive
transfer of the central programmes to the states. It is claimed that the Central
Government has technical and management expertise. This is doubtful. However, States
8
should be free to avail of any such expertise wherever and whenever available.
NHP-1983 clearly voiced for disbanding vertical programmes. Unfortunately, this was
not only disregarded but new vertical programmes were introduced. Some wisdom and
enlightenment seem to have taken place. We have to wait and see what happens.
The verbose statement under NHP-2001 lacks the clarity and vision that are
required to take appropriate actions for implementation. The main cause of the present
dismal situation of the national health programmes in excessive centralization,
administrative inadequacy and poor management. All the schemes converge and get
connected at the community level, viz. the villages or urban blocks. All that is required
to start full decentralization and transfer of powers, authority and adequate resources to
PRIs. Necessary empowerment, guidance and technical support should be provided
without any hesitance and uncertainty. Further details should be left to the Zilla
Parishads to decide. If the Central and State Governments can do this without further
loss of time, within a short span of five years at least 30 per cent of the villages will be on
their own and give better performance in all health and developmental activiti NHP-1983
es. To the extent primary health care facilities develop, most of the basic health needs of
the people will be satisfied.
4.4 THE STATE OF PUBLIC HEALTH INFRASTRUCTURE:
Section 2.4 acknowledges the unsatisfactory state of the health infrastructure.
This includes medical care, funding, field staff and supervision, equipment and supplies,
poor physical facilities and what not. The policy aims to correct the deficiencies. It is,
however, silent on the quality and performance. Comments on the new policy provisions
are:
4.4.1 The process of decentralization as suggested in item 4.3, will take care of the
problems of infrastructure also. Unfortunately, as else where in the draft policy
document, the focus is on curative medical care rather than health care. Most of this item
is devoted to the supply of medicines. People come to the Primary Health Centres for
care by a doctor and not for medicines per se. The main issue about the drugs is that the
essential drugs are not easily available at all times and places. In most of the cases, even
the essential drugs are sold in brand name at high cost. It is essential to bound all the
retail chemists to ensure unrestricted supply of essential drugs under generic names at
low cost. The rest will take care of itself.
4.4.2 Data in Box V give international data on health status and expenditures. It shows
that our neighbours, China and Sri Lanka have performed better than us even at a lower
level of expenditures. On this basis, NHP-2001 proposes to strengthen health
infrastructure and levying user-charges for speciality medical care. While both these
actions may be necessary, they cannot flow out of the data in Box V. The difference is
due to factors such as a strong and capable public health system, decentralization, public
health expertise, efficient management, and judicious and cost-effective use of the funds.
9
4.5 EXTENDING PUBLIC HEALTH SERVICES
While accepting the failure to provide medical manpower in the rural areas,
section 2.5 makes a plea to deploy nurses and para-medical staff for overcoming the
difficulty. This approach is obviously wrong, especially on the other side, the draft talks
about equity, etc. It also mentions about the utilization of practitioners of ayurvedic and
other systems of medicine to reach the extended areas far off. However, under the new
policy, the point raised is about the use of practitioners of other systems of medicine and
paramedical manpower. There is nothing like extension of any kind of service. This is
largely administrative matter rather than policy concern. Some of the phrases are difficult
to understand, e.g., ‘.... in a prescribed functional area adjunct to their current functions
.
Item 4.5.2 is a totally redundant issue.
4.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS
The paragraph jander section 2.6 records the fact that PRIs have been successful in
improving the health services management and general developmental activities.
Undoubtedly, decentralization of the primary health care, is the inevitable solution we
have. Sooner we do it, the better. This has to be done fully and not half-heartedly. This
is one of the most vital issue, but it is mentioned in NHP-2001. The necessity and
possible impact of full decentralization, etc., have been covered earlier under item 4.3.
This is the most important and indispensable matter.
4.7 MEDICAL EDUCATION
Medical education is studded with problems. Recently, Planning Commission has
had a Special Consultation on Medical Education. It was useful and report on this
exercise will be of great use. Within the medical manpower, there are serious distortions.
Some of these are mentioned in section 2.7. Unfortunately, there is mention also of
research causing confusion. The following are the comments on the new policy:
4.7.1 It is proposed to set up a Medical Grants Commission. It is a good move.
However, by itself, this will not solve the problems of relevance, quality, etc.
4.7.2 Medical education is studded with problems. These are being debated for
decades. Merely changing curriculum will not help. Recently, Planning Commission has
had a Special Consultation on Medical Education. Wc do need family doctors and a new
course leading to Masters degree in Family Medicine may be considered. Its report will
be of use.
4.7.3 This is too simplistic and isolated approach like this will serve no purpose.
4.8 NEED FOR SPECIALISTS IN PUBLIC HEALTH & FAMILY MEDICINE
It is stated in section 2.8 that public health expertise is non-existent in private
sector. However, this is more true of the public and government sectors. It is true that
io
the institution of general practitioners of family doctors is declining. The policy is
expected to ensure availability of these two categories of manpower. Unless this is done
on war-footing, there will be no success. It should be noted that we do not have training
facilities, worth the name, for these two categories of manpower that is essential for
public health practice. In the proposed policy, the point is well taken. However, the
measures recommended exposes profound ignorance about medical education and health
manpower training of those responsible to draft this paragraph. The problem cannot be
solved just by raising the postgraduate seats. Public health specialists cadnot be trained
in medical colleges, any way. The proposal to allow non-medical graduates to get trained
in public health is a welcome move. However, this issue need to be deliberated before
decision is made.
4.9 URBAN HEALTH
As mentioned in section 2.9, this is a neglected field and situation will become
grave with rapid urbanization. Comments on the provisions under new policy are:
4.9.1 Replicating rural infrastructure in urban setting, even in a modified way, is not
needed because it will not serve the purpose. In fact, PHCs may soon become redundant
even in the rural areas. Private services will predominate. Municipalities already have
the dispensaries, maternity homes, etc. Appropriate strengthening and modifications may
be necessary. Again all this talk is about medical care and not health care. In the present
form the draft national health policy is defective in many ways, including the portion on
urban health. It has to be redrafted by experts. 4.9.2 also falls in this category. Setting
trauma centres may prevent few deaths due to accidental injuries. In public health, it is
essential to prevent accidents. The basic health need of the urban areas, which require
urgent attention are: (a) proper housing, (b) adequate and safe water supply, (c) sewerage
and sewage treatment plants, (d) solid waste disposal, (e) general sanitation and hygiene,
(f) control of environmental pollution, (g) occupational health and safety, (h) slum
improvement and prevention, (i) sports and recreational facilities, and (j) safe transport.
4.10 MENTAL HEALTH
As mentioned in section 2.10, this is an important issue. Unfortunately, curative
bias is again naked here. Policy drafters could not think beyond the hospitals and
psvchiatrists. This will certainly not do any good to mental health and hygiene.
However, the new policy only covers treatment of mental disorders and opening
treatment centres supported by the Government of India. It is not understood, however,
relevance of all this to the human rights, etc. Requirements for good mental health are:
stress reduction, recreation, sports, creativity centres, picnics and touring for sight
seeing..
4.11 INFORMATION, EDUCATION AND COMMUNICATION
11
Under section 2.11, more has been said about this vital intervention, but very little
action and impact. Isolated and ad hoc programmes cannot be ever effective. We need
well-planned comprehensive and integrated programme to be sustained as a long term
and dynamic activity. We have been talking about students for decades. We have failed
to teach subjects for which students have joined educational institute, and we are talking
about health. We have never bothered to involve the concerned such as Education
Departments. Below are the comments on the draft of the new health policy:
4.11.1 The write-up on IEC is all right. However, the question is how to go about. This
operational aspect has not been covered. In fact, this is the main failing of the draft.
4.11.2 School health is being talked of for last fifty years. Let us first teach and educate
our children well. Provide good school premises and sanitary facilities. Health and
health education will follow.
4.12 MEDICAL RESEARCH
This item is introduced in section 2.12. Research in India has not contributed
much to better health to our people. This is after spending 1,150 crores in 1998-99, just
one year. We need to review and reorient research programmes for development rather
that building empires without substance. The move under NHP-2001 to provide more
funds for research is good. However, again the same bias for medical care. It will be
wrong to focus research on drugs. This is essentially the function of the pharmaceutical
manufacturers and involvement of medical colleges. Their investments are high and
government cannot match it. It is desirable to encourage Indian companies to do it. We
have a national institute in Lucknow. Do not starve it. Medical research in India, which
is essentially repetitive, needs to be totally reoriented. Health care should get priority.
The thrust areas should be: (a) health services/systems, (b) data-base for policy
formulation, (c) testing developmental interventions and programmes for efficacy,
feasibility, cost-effectiveness and cost-benefits, and wider application in diverse
epidemiological and socio-economic conditions, (d) evaluation of on-going health
programmes and services for mid-term corrections, if needed, (e) data-base for planning,
(f) data-base for setting priorities, (g) mission oriented basic and advanced research for
which about 30 per cent of the research funds should be allocated.
4.13 ROLE OF THE PRIVATE SECTOR
Section 2.13 offers to regulate private medical practice, and rationalize treatment
procedures. Other question is about the role of private sector in the public health system.
Below are the comments on the new policy:
4.13.1 It is a correct move to control, prescribe standards, ensure quality and fairness,
etc., in the practice of medical care through legislation. This should equally apply to the
12
public sector also. It is necessary to ensure that high standards are maintained in treating
all major diseases by the private and government doctors.
4.13.2 The question of treating foreign nationals in India is purely an economic issue.
Such treatment is being already provided by many hospitals in India. There is no need to
have any policy on it or to create problem by regulating it, except payments made in
foreign hard currency.
4.13.3 This is very restricted approach. It is essential to involve non-government experts
in all aspects of policy formulation, planning, implementation, evaluation and
assessment, research, etc. to the advantage of the government. In fact, there is urgent
need to set up advisory and consultant committees to the health ministries and
directorates at the central and state governments.
4.13.4 Tele-medicine is already being in vogue and expanding. There is no need to have
any policy on it. Such things evolve and develop by themselves by the entrepreneurs.
4.14 ROLE OF THE CIVIL SOCIETY
Section 2.14 covers the areas of involvement and participation of the people and
the non-govemment organizations in health development. This is the issue of the role of
the voluntary organizations and other types of NGOs vis-a-vis that of the government
organizations. The write-up in NHP—2001 is too simplistic and very narrow. As
mentioned under the item on urban health, the present form the draft national health
policy is defective in many ways. It has to be totally redrafted by experts.
4.15 NATIONAL DISEASE SURVEILLANCE NETWORK
The title of section 2.15 really means epidemiological surveillance system. We
have none. We cannot have it either unless we put our public health system on the
ground. We have to have decentralized system of information, its regular and critical
analysis and correct interpretation. Such a surveillance system will serve no purpose
unless this is backed up with efficient public health services capable of quickly initiating
investigation and appropriate containment measures. We have very long way to go. The
measures covered in the new policy will not be of much effect. Present system is at best
rudimentary and not effective. We cannot have it unless we put our public health system
on the ground. We have to have decentralized system of information, its regular and
critical analysis and correct interpretation. Further, such a surveillance system will serve
no purpose unless this is backed up with efficient public health services capable of
quickly initiating investigation and appropriate containment measures. We have very
long way to go.
4.16 HEALTH STATISTICS
13
Secion 2.16 goes to the extend of mentioning a system of national health account,
etc. There will be no statistics unless we feel need for informed decision making in our
management of health services and development. We have no efficient system to record
vital statistics. Unless this basic scientific need and information for decision-making, we
shall continue to manage without information. Unless we are able to build strong public
health system, we shall not get data we need.
It is surprising that NHP-2001 expects to have the baseline data on diseases such
as tuberculosis, malaria and blindness for the control of which we have long standing
control programmes, to be completed as late as 2005. The proposed exercise is actually
superfluous. If we care to adequately strengthen the public health system in the country,
the problem of health statistics will get resolved automatically.
4.17 WOMEN’S HEALTH
Para 2.17 suggeste need to do something to empower women. However, there is
no need to have separate programme for this because all aspects of women’s health are
covered under the reproductive and child health programme with its broad lifestyle
approach.
4.18 MEDICAL ETHICS
Section 2.18 speaks about genetic and molecular biology research and associated
moral issues, rather that things like doctor-patient relations, exploitation, irrational use of
drugs, unwanted investigations and diagnostic procedures, high cost of medical care, etc.
In the new policy, following are the provisions:
4.18.1 Contemporary code of ethics will be notified, Medical Council of India to enforce.
4.18.2 While there will be no policy on genetic and molecular biology research and
associated moral issues, it is proposed to maintain vigilance.
4.19 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DRUGS
This matter under section 2.19 is an issue of enforcement of drug and food related
Acts and regulations. There is little of policy. Question is of integrity and honesty. The
new poliy states that the food and drug administration will be strengthened, and standards
enhanced.
4.20 REGULATION OF STANDARDS IN PARA-MEDICAL DISCIPLINES
This issue, mentioned under section 2.20 is more-or-less of the same nature as of
food and drugs. The new policy proposes to establish statutory professional councils for
14
paramedical disciplines. This seems unnecessary because this function can be assigned to
the universities of health sciences.
4.21 OCCUPATIONAL HEALTH
This item under para 2.21 is the matter of enforcement of the existing laws and
regulations in the interest of health and safety of the health of the workers. t
New policy proposes periodic screening of the workers will be retrograde step,
unless the occupational health services are well established. Working conditions of the
workers should first be improved, made safe and pollution free.
4.22 PROVIDING MEDICAL FACILITIES TO USERS FROM OVERSEAS
This is not a policy concern. It is a pure fiscal matter of the concerned authorities.
4.23 IMPACT OF GLOBALIZATION ON HEALTH SECTOR
Section 2.23 gives a preamble. The impact will not only raise the cost of
medicines and treatment, but result in distortions in our policies and priorities. The poor
will not be benefited. Economic reforms, privatization and structural adjustments have
made the fiscal matters worse. There is progressive reduction in the allocation of funds
for public health and other social sectors. When it comes to structural adjustments,
budgetary deficits are adjusted by reducing the capital expenditures and cuts in
operational expenditures. Adjustments are not done by downsizing and delayering of the
organization. Economic reforms have not helped in fashioning a good public health
system which benefits the poor.
The draft policy speaks only of TRIPS. Globalization will not only raise the cost
of medicines and treatment, but result in distortions in our policies and priorities. The
poor will not be benefited. Economic reforms, privatization and structural adjustments
have made the fiscal matters worse. There is progressive reduction in the allocation of
funds for public health and other social sectors. When it comes to structural adjustments,
budgetary deficits are adjusted by reducing the capital expenditures and cuts in
operational expenditures. Adjustments are not done by downsizing and delayering of the
organization. Economic reforms have not helped in fashioning a good public health
system which benefits the poor.
5.0 SUMMATION
5.1
This portion of the draft reveals that the basis of formulating this draft policy was
purely clinical facts. As claimed, this may define a ‘vision’ for medical care, but
certainly not for health care. We are planning health policy and not policy foe medical
care. Thus, the exercise has to be redone.
15
5.2
Here it is acknowledged that draft NHP-2001 does not claim to be a road-map for
meeting all the health needs of the populace of the country. Unfortunately, this is the
case and in many ways this 28 page verbose draft cannot be considered a policy
document.
5.3
Equity is very important issue. However, this cannot be the primary focus of any
health policy formulation. Secondly, the claim that by meeting the minimum health
needs of the citizens, equity will be ensured, is not correct.
5.4
The basic principle that health development has to b an integral part of total socio
economic development, has been either ignored or missed. Therefore, the draft policy
should be dropped and the exercise assigned to a small team of experts. This team shall
have to consult, involve and co-opt experts and authorities of all the health related
developmental sectors.
CONCLUSIONS AND RECOMMENDATIONS:
1. The draft NHP-2001 is not acceptable. It is antithesis of NHP-83. However,
NHP-83 is still largely valid. The problem is that the Government has failed to
follow it. Quick and easiest alternative to up-date it, and make its strict
implementation obligatory.
2. Second alternative is to assign the task of formulating the national health policy to an
independent group of four to five non-govemment experts.
3. The guide lines for policy formulation are essential, NHP-83 should be the
reference.
4. Major terms are to be defined, e.g.,
Primary Health Care Approach : Health cannot be isolated from development.
Health of the people will improve only if steps are taken concurrently for development in
all walks of life. Primary health care is an essential health care based on practical,
scientifically sound and socially acceptable methods and technology, made universally
accessible to individuals and families in the community through their full participation
and at a cost that the community and country can afford to maintain at every stage of their
development, in the spirit of self-reliance and self-determination. All the planners,
administrators and managers should comprehend this meaning and scope of primary
health care approach. The target groups must be all those people (rural poor and urban
slum dwellers; and people in tribal, backward and inaccessible areas) who do not have or
cannot avail of even the bare minimum of the health care facilities. The following are the
cardinal elements of primary health care :
a. Health Education about prevailing health and medical problems, and methods of their
identification, management, prevention and control.
b. Adequate food supplies and proper nutrition.
i
16
c. Safe and adequate water supply within one’s reach, and basic sanitation, viz.
the
sanitary disposal of excreta and refuse, and housing.
d. Health care of mothers and children, including family welfare.
e. Immunization against major communicable diseases.
f. Prevention and control of locally endemic diseases.
g. Elementary care and appropriate treatment of common diseases and injuries.
h. Provision of essential drugs.
Unless all these elements are provided adequately and continuously without
interruption, primary health care will have no meaning. These are the minimal essential
health needs. Within these, there are no priorities. This must be a wholesome package.
Primary health care is an approach for providing HFA, and not a programme by itself. It
is neither rigid nor dogmatic. For primary health care, the basic principles should be
observed precisely. Other Prerequisites and Stipulations are:
a. Health care facilities should be developed and arranged around the life patterns of the
population it is expected to serve, and should meet the needs of the community.
b. Primary health care should be an integral part of the health services at Primary Health
Centres, and Community Health Centres. District and other special hospitals, medical
colleges, etc., should function in support of the primary health care for technical,
logistical, supervisory and referral services.
c. Decentralization is essential to ensure that local needs of the community are fulfilled.
d. Other developmental sectors such as agriculture, education, public works and housing,
communications, social welfare, etc., should be involved actively. Multi-sectoral
co-operation and collaboration are the key factors. An individual or society is often
a victim of social, cultural and traditional practices existing within the community.
This necessitates search for the solutions which are multi-dimentional and multi
directional. Equity and accessibility demand special attention to vulnerable and needy
groups. Technology used should be appropriate, i.e., it is effective, simple to use,
acceptable, and sustainable.
e. Community participation is indispensable for the success. Effective leadership at all
levels is an important factor. Often, it is imperative to empower the people and organize
the community so that it can truly participate. Concrete inputs to empower people are
- Information, Education and Communication (IEC), income generation and authority.
f. Political will is an important limiting factor. Full political support and pledge are vital.
Basic determinants of public health and bare truth:
“Health care” is often confused with medical facilities. This is not true. Medical
care is only a part of health care and comes into operation whenever there is deviation
from health, i.e., when illness prevails. Health status is determined by three basic factors,
viz.
•
Healthful environment, specially safe drinking water supply, sanitary disposal of
excreta and other wastes, and pollution-free housing and work places.
17
•
•
Adequate nutrition which in turn depends on production and availability of foods,
ability to purchase proper foods, personal and food hygiene, and freedom from
infections.
Lifestyle: important components being health information and education, status of
women, economic status, human behaviour and attitude, social and moral values,
social justice and equity, health and medical facilities, etc. What matters generally is
up-bringing of children by parents, and influence of the circumstances qnd personality
development from the childhood at the family and school levels.
It is clear that most of these areas are outside the direct scope of the government
health departments. However, our so-called health services have failed to recognize that
health care is interdisciplinary and multi-sectoral. Without striving and actively
interacting with the concerned developmental sector, the ‘Health Services’ by and large
provide only the curative, i.e., medical services which are often of poor quality and not
satisfying to the many sick persons who attend the health centre or hospital.
Basic requirements of public health services
The minimum expectation from public health care is ‘freedom from epidemics’.
The following are some important aspects(of a strong public health system:
•
•
•
•
•
•
The control and prevention of common communicable and non-communicable
diseases. Environmental health must be an integral component of this activity.
Reduction of mortality, morbidity and disability. This involves development of
multi-disciplinary and multi-level health manpower.
Information, education and communication (IEC) effort to empower the people to
become self-reliant in matters of health. The main objective is to encourage lifestyles
which are conducive to better health.
Training and development of multi-disciplinary health manpower. This should be
properly deployed and competent to satisfy the health needs of the community.
Research directed to solving health problems and ensuring progress. This involves
health systems research for optimum use of available knowledge and technology for
welfare of the people and better quality of life.
Providing advocacy and securing community participation, and collaboration and
cooperation of other developmental sectors.
Procuring adequate resources, including finance and strong public support.
5. Objectives and major items to be addressed in the new health policy are as
follows:
•
•
Strengthening of the public health system in the country.
Full and unrestricted transfer of primary health care and related development
programmes below district level to PRIs and Nagar Palikas. It is essential to provide
necessary authority and administrative powers, adequate funds and other resources,
technical and consultation support, training facilities, periodic assessment, etc.
18
Empowerment of the people and local leadership for successful and efficient local
governance.
• Development of critical mass of about 150 public health experts within next two to
three years. There are no facilities in the country to do this efficiently. Selected
officers should be trained abroad at carefully selected schools of public health in
America, Europe and else where.
Training should cover both basic and
superspeciality aspects of public health and health management.
• To attract talent and ensure career development in public health, Indian Public Health
Service should be established, on par with that of IAS and IPS.
• Six national (not regional) schools of public health should be established urgently, if
possible with external funding. By the time buildings, etc., come up, the about
mentioned trained persons will be available as a faculty.
• The experts trained abroad, will be deployed to the top health management posts in
the Central and State Governments.
• Decentralized planning should be mandatory. It should start from the Gram
Sabha/Ward Committee and progress upwards to Zilla Parishad and Nagar Palika,
respectively. Integration and coordinating district plans will be the function of the
State Planning Board. Government of India will have its own plan.
• Organizational restructuring is indispensable. There is need to down-size and down
layering it, both at the central and state levels. District organization, however, need
substantial strengthening.
• While quality and affordable medical care has to ensure, the main thrust of the policy
should be health care and health development. Medical care of all, perhaps with
exception of the families below poverty line and the indigent elderly, should be the
function of the private sector. In fact, there should be no need to cover the treatment
of disease as a part of any disease control programme. Health care, prevention of
disease and promotion of health and well-being should be the function of the
government, public and corporate sectors.
• Asa watch dog, it is necessary to establish efficient epidemiological services.
• The last, but most important, is the issue of inter-sectoral co-operation and
coordination in all developmental efforts including for health promotion. Public
health in essentially multi-disciplinary. It, in practice, has to become transdisciplinary. Therefore, all the concerned ministries and departments, and respective
experts should be the joint and active partners in the exercise of drafting and
finalizing the national health policy.
•
Diagram II shows a rational approach for formulating a national health policy.
Diagram II: Rational Approach to a National Health Policy
19
Health Status
m
ft
Comprehensive Health Services
Integrated Medical and Health Care
Policy
...... jy"""""''1' .
H
Health
National
E
n
H v
e i
a r
1 o
t n
h m
y e
n
t
L
H i
e f
a e
1 s
t t
h y
y 1
e
......
ZZZZ
.......
......
(Concept, idea and design by NSD)
*
*
*
*
*
e
a
S 1
t t
r h
o
n S
g y
s
t
e
ft
20
DRAFT NATIONAL HEALTH POLICY-2001, A CRITIQUE
EXECUTIVE SUMMARY
by
Dr. N. S. Deodhar, Health Consultant, Pune
GENERAL REMARKS :
The draft policy statement is unintelligible, gives misleading statistics, needs
prose editing and scientifically irrational. It will not take the nation on the path of health.
Many statements are not substantiated. Information on present scenario, does not provide
data which are essential for formulating health policy. In marked contrast with its neglect
in India, term ‘public health’ is used generously. However, nothing can be achieved just
by suffixing the word ‘public’ to health. The common terms such as public health and
primary health care are not understood. Diagram I summarizes epidemiological status of
the proposed national health policy. The draft is a death notice to public health and
cannot be approved.
NATIONAL HEALTH POLICY-1983 :
1. Many noteworthy initiatives of NHP-1983 are still valid. However, none of these
find place in the new policy.
2. NHP-1983 suffered from contradiction between its profession and practice from very
inception. It was ignored by the authorities. Therefore, it is desirable that the new policy
should come as a legislative act and not just a statement. Non-observance should be open
for judicial case and punishable.
3. The main thrust of 1983 policy was the Nation’s commitment to provide universal
access to basic health facilities through primary health care approach. This and other un
finished agenda cannot be allowed to lapse un-met in the new policy.
CURRENT PUBLIC HEALTH SYSTEM SITUATION :
1. It is common knowledge that the system is not functioning satisfactorily, people are
not happy and has failed to reduce morbidity.
2. Unless the developments since NHP-83 are correctly assessed, it will not be possible
to have necessary relevant, appropriate and valid data-base for formulating NHP-2001.
3. Programmes to control communicable and non-communicable diseases have failed.
Public health system is so weak that it is unable to contain epidemics and prevent
recurrences. A major issue is the poor management and lack of expertise in public health.
4. Over years the public health system has become so moribund that it can do only one
thing at a time and that too badly, and adversely affecting every other function.
21
5. Funds are neither fully utilized nor used cost-effectively. Disproportionately larger
funds are provided for medical care. This results in poor funding of primary health care
to the common people, and capacity building of nursing, paramedical and field personnel.
DRAFT NATIONAL HEALTH POLICY-2001 :
In a nutshell, the draft, policy document is a joke. It is antithesis of NHP-83.
1. The objective are not explicit. Increasing the health expenditure cannot be a goal. The
goals and target years are selected arbitrarily
2. It makes a wrong plea that unless the States are funded by the Central Government,
they will not be able to take their constitutional responsibility for public health.
T Tt jumbles issues eouitv and access.
4. New policy recognizes the need for flexibility of the national health programmes and
allowing the States to formulate their own programmes. It also talks of progressive
transfer of the central programmes to the States.
5. It acknowledges the unsatisfactory state of the health infrastructure. However, it
hopes to improve the situation by its expansion. Non-functioning is due to poor
management.
6. The new policy focus is on curative medical care rather than on health care.
7. It is proposes setting Medical Grants Commission. However, by itself, this will not
solve the problems of medical education, relevance, quality, etc.
8. It asks for public health specialists and family doctors. However, the suggestions for
training them are all wrong. The proposal to allow non-medical graduates to get trained
in public health is a welcome move.
9. Replicating rural infrastructure in urban setting, even in a modified way, is not needed
because it will not serve the purpose. Setting trauma centres may prevent few deaths, but
will not prevent accidents. Health need of the urban areas are: proper housing, water
supply, sewerage and sewage treatment plants, solid waste disposal, general sanitation
and hygiene, control of pollution, occupational health and safety, and safe transport.
10. . It’s research focus is only on drugs. Thrust areas should be: health services/systems,
data-base for policy formulation, testing developmental interventions and programmes for
efficacy, feasibility, cost-effectiveness and cost-benefits, and wider application in diverse
epidemiological and socio-economic conditions, data-base for planning, and mission
oriented basic and advanced research.
11. The write-up on NGOs is too simplistic and very narrow.
12. Contemporary code of ethics will be notified, Medical Council of India to enforce.
13. The food and drug administration will be strengthened, and standards enhanced.
14. The new policy proposes to establish statutory professional councils for paramedical
disciplines. However, this can be done by the universities of health sciences.
15. It proposes periodic screening of the workers. This will be a retrograde step.
Working conditions of the workers should first be improved, made safe and pollution
free.
16. The draft speaks only of TRIPS. Globalization will not only raise the cost of
medicines and treatment, but many other adverse effects will be there also
22
17. A policy based purely on clinical experience, may define a ‘vision’ for medical care,
but certainly not for health care.
18. NHP-2001 does not claim to be a road-map for meeting all the health needs of the
populace of the country.
19. The basic principle that health development has to be an integral part of total socioeconomic development, has been either ignored or missed.
RECOMMENDATIONS:
1. The draft policy should be dropped.
2. The main objective should be to address current developmental problems.
3. Items to be attended are: (a) strengthening public health system and ensure and
effectiveness of public health practice and programmes, and (b) raising the standard of
health and quality of life. NHP-83 should be the reference.
4. Quick and easiest alternative to up-date NHP-83, making implementation obligatory.
5. Second alternative, is to assign the task of formulating the national health policy to an
independent group of non-govemment experts. Health care is trans-disciplinary.
Therefore, all the concerned ministries and departments, and respective experts
should be the joint and active partners in drafting and finalizing the national health
policy.
6. Pending fresh exercise for health policy formulation, actions immediately required
are:
• Full and unrestricted transfer of primary health care and related development
programmes below district level to PRIs and Nagar Palikas. It is essential to provide
necessary authority and administrative powers, adequate funds and other resources,
technical and consultation support, training facilities, periodic assessment, etc.
• Empowerment of the people and local leadership for efficient local governance.
• Development of critical mass of about 150 public health experts within next two to
three years. There are no facilities in the country to do this efficiently. Selected
officers should be trained abroad at carefully selected schools of public health in
America, Europe and else where.
Training should cover both basic and
superspeciality aspects of public health and health management.
• To attract talent and ensure career development in public health, Indian Public Health
Service should be established, on par with that of IAS and IPS.
• Six national (not regional) schools of public health should be established urgently, if
possible with external funding. By the time buildings, etc., come up, the about
mentioned trained persons will be available as- a faculty.
• The experts trained abroad, will be deployed to the top health management posts in
the Central and State Governments.
• Decentralized planning should be mandatory. It should start from the Gram
Sabha/Ward Committee and progress upwards to Zilla Parishad and Nagar Palika,
respectively. Integration and coordinating district plans will be the function of the
State Planning Board. Government of India will have its own plan.
23
•
•
•
•
Organizational restructuring is indispensable. There is need to down-size and down
layering it, both at the central and state levels. District organization, however, need
substantial strengthening.
Medical care of all, perhaps with exception of the families below poverty line and the
indigent elderly, should be the function of the private sector. In fact, there should be
no need to cover the treatment of disease under any disease control programme.
Health care should be the function of the government, public and corporate sectors.
Asa watch dog, it is necessary to establish efficient epidemiological services.
Proactive role in inter-sectoral co-operation and coordination, is a priority.
Diagram II shows a rational approach for formulating a national health policy.
Page 1 olo
vhai
From:
To:
Cc:
Sent:
Subject:
"DBanerjee" <nhpp@bol.net.in>
<nihfw@delnet.ren.nic.ln>
"Muraleedharan" <vrm@iitm.ac.in>; "Dr.Samir Chowdhury" <cini@cal.vsnl.net.in>;
"halfdan.mahler'’ <halfdan.mahler@bluewin.ch>; "hemalatha" <hemalatha@hivos-india.org>;
"Mrs.sanghmitra Sheel Acharya" <acharya@now-india.net.in>; "Prem John"
<prem@md2.vsnl.netin>; "Rami Chhabra" <aalna@del3.vsnl.netin>; "mathura shreshta"
<mathura@healthnet.org.np >; "vhai" <vhai@del2.vsnl.net.in>
Sunday, September 09, 2001 6:11 AM
Comments on the 2001 Draft Health Policy
Professor M C Kapilashrami, Director, NIHFW.
.
: i
'
,
r
Dear Professor Kapilahrami
I am enclosing my comments on the 2001 Draft Health Policy for favour of
circulating them among the Faculty Members of NIHFW and to the Members of
its Governing Board. Unfortunately, the E-mail to Shri Javed Chowdhury and
Ms Sujata Rao was returned to me, stating permanent error. Could you also
arrange to get it sent to them?
If there is any proposal to discuss the comments either at N1HEA or at the
MOHFW, I will be glad to participate.
With regards,
Sincerely yours,
D Bancrji
---- Original Message----From: DBanerjee <nhpp@bol.net.in>
To: <aeabop@nb.nic.ln>
Cc: pha-ncc <pha-ncc@yahoogroups.com>
Sent: Saturday, September 08, 2001 5:26 PM
Subject: [pha-ncc] 2001 Draft Health policy
September 8 2001
AN IMMEDIATE/INTERIM RESPONSE TO THE DRAFT
NATIONAL HEALTH POLICY 2001
Dcbabar Banerji,
Professor Emeritus,
Jawaharlal Nehru University,
and
Convenor, Nucleus for Health Policies and Programmes,
B-43, Panchsheel Enclave, New/delhi 110017.
Tel:649 0851 & 649 8538E-Mail:: nhpp@bol.net.in
9/26/01
Page 2 oi.O
H
f
j
> 1. As one who has been involved in health policy studies for over four
> decades, 1 thought 1 must get together my experiences and ideas to offer
my
> comments on the Draft.
x
> 2. As the time limit for comments is woefully inadequate, I am responding
> within 12 hours of receiving the draft. 1 have made an effort to keep my
> effort ruthlessly brief - about one tenth of what I ought to write. I
> certainly will not be comprehensive in this very brief presentation. I
will
> be glad to elaborate any points that may asked for.
I
> 3. MY MAIN COMMENT IS THAT A DOCUMENT THAT CLAIMS TO BE A POLICY
INSTRUMENT
> IS CONSPICUOUSLY WANTING IN FOLLOWING SOME OF THE BASIC TENETS OF THE
WELL
> RECOGNISED AREA OF POLICY STUDIES; IT SIMPLY "HANGS IN THE THIN AIR" , AS
IT
> WERE, WITHOUT A PAST, FUTURE OR EVEN A SEMBLANCE OF UNDERSTANDING C
THE
> FACTORS WHICH HAD AND WHICH WILL INFLUENCE POLICY FORMULATION AND
ITS
> IMPLEMENTATION. IT IS AHISTORICAL, APOLITICAL, ATHEORETICAL AND IT
LACKS
IN
> BASIC ACADEMIC RIGOUR REQUIRED FOR THE TASK.
>
> 1. THE DRAFT
> 4. Before I start with a critique, I will express my admiration for the
> excellent way it has been written, in sharp contrast with the confused not
> very coherent or cogent way the the 19982/83 Policy was written and
> presented. I admire the 55-35-15 per cent formula for distribution of
> resources for primary, secondary and tertiary levels. I particularly note
> the mention of the phrase "scientifically optimum" advocacy for programme
> formulation. As the subsequent analysis will show, this phrase was
probably
> used in a state of absentmindedness!
> 5. Even if we ignore the fact that the Draft "hangs in thin air", it is
> bristling with infirmities. Only a few instance will be sufficient to
expose
> the infirmities:
> a. It is deafeningly silent on the critical question of health
> administration - from the very top to the bottom. The Draft has not
> confronted the critical issue of vivisection of the Ministry of Health
into
> the very endowed Department of Family Planning/Welfare and the
> neglected Department of Health. The Family Planning Department has been
> acting as a "as a raging bull in the China shop" of the health services of
> the country for more than three decades and a half! It has not only
> devastated
> the health services of the country, but it has miserably failed to attain
> its objectives, as seen by decadal increases in the population (from 351m
9/26/01
Page j ol0
in
> 1951 to 1006m in 2001) which arc horrendously correlated with astronomical
> growth in the allocations - Rs6.5m in the the hirst Plan to Rs65,000 in
the
> Eighth Plan; GREATER THE ALLOCATION, GREATER IS THE RISE IN POPULATION
> GROWTH - AND GREATER IS THE DAMAGE TO THE HEALTH SERVICES! Those
> responsible were not held accountable for this disaster. Surely the
authors
> of the 2001 Policy
> arc aware that in the state of Uttar Pradesh where there arc five
positions
> of
> secretaries in the Department of Health and Family Welfare - one each for
> family welfare, health, medical care and medical education, with an
> ovcraching Principal Secretary to oversee their work!
> b. After the abolition of the cadre of the Indian Medical Service, there
> has been a steep decline in the quality of the leadership
> from medical personnel. Critical public health posts at the Union and
State
> levels arc occupied by persons who lack basic competence for the jobs. The
> Draft overlooks the blatant anomalies in the structure of the Central
Health
> Service.
> c, There is a blatant contradiction in the draft concerning the Vertical
> Programmes.
> After pointing out their incongruity and extremely poor
cost-effectiveness,
> the Draft wants these to go on till the diseases are controlled. This is a
> prescription for their "eternal" continuation, if we look at the
programmes
> like malaria and tuberculosis - and, of course, Family Planning.
> d. The approach to medical education is patently unacademic. Has the UGC
> increased the quality of higher education of India? What can we expect
from
> the Medical Education Commission, which is being lobbied for at least four
> decades? What is our experience with medical universities? What about the
> politics driven private medical colleges? Do the authors know that a
recent
> survey of medical colleges (NATIONAL MEDICAL JOURNAL OF INDIA) showed that
> about 90 per cent of them do not conform to most elementary requirements
of
> a teaching institution?
c. The authors do not seem to have learnt from the original sin committed
> in West Bengal in the seventies to train Health Assistants; now they arc
all
> agitating for a condensed course get the MBBS degree!
1 would end this here. The list can go on and on for quite some time.
9/26/01
i . i u
i
> 11. TOTAL NEGLECT OF BASIC POSTULATES OF POLICY STUDIES
>
> 6. The authors of the Draft do not seen to have understood that health
> policy formulation is a (i) socio-cultural, (ii) political, (iii)
economic,
> (iv) technological, and (v) organisational
> and managerial process, with profound (vi) epidemiological and (vii)
> sociological dimensions. It is not a "secretarial" process. I have
discussed
> these issues in a paper with title: A SIMPLISTIC APPROACH TO HEALTH POLICY
> ANALYSIS: THE WORLD BANK TEAM ON THE INDIAN HEALTH SECTOR,which I had
> insisted on publishing in our own ECONOMIC AND POLITICAL WEEKLY (June 12
> 1993, pp.1207-1210). It was also reprinted in the INTERNATIONAL JOURNAL OF
> HEALTH
> SERVICES (vol.24, no. 1,1994). Incidentally, one of the persons whom the
> World Bank
> Team had identified as a "Health Policy Expert" was the then Secretary,
who
> had then recently been transferred to the the Health Department from some
> other Ministry. He was later identified by DaVdson Gwatkin, the Director
of
> the World Bank Center for Health Policy Studies at Washington to prepare a
> health policy document for India. It would be interesting to know whether
> that document was used in formulating the 2001 Draft. I had also discussed
> these issues in
> considerable detail in my book, HEALTH POLICIES AND PROGRAMMES IN INDIA
IN
> THE EIGHTIES: A CRITICAL APPRAISAL (New Delhi, Lok Paksh,1990).
> III. THE NATIONAL HEALTH POLICY OF 1982-3 AND THE 2001 DRAFT
> 7. One of the features of the 2001 Draft which strikes one with great
force
> is
> the almost a total neglect of the postulates of the NHP of 1982. Under
these
> circumstances, it is not surprising to find any mention whatsoever of the
> Alma Ata Declaration oh Primary Health Care, or the 1977 Programme of
> entrusting ’Peoples’ Health on Peoples’ Hands", what to speak of the Bhore
> Committee Report of 1946 or that of the Sokhcy Committee of 1942.
> I had devoted a great deal of attention to the NHP-1982 in the magnum
>opus I
> wrote in 1985, with the title: HEALTH AND FAMILY PLANNING SERVICES IN
INDIA:
> AN EPIDEMIOLOGICAL, SOCIO-CULTURAL AND A POLITICAL ANALYSIS AND A
> PERSPECTIVE. I was apparently somewhat naive in expecting some movement,
> particularly as it has the approval of the Parliament.
> 1 would quote from the NHP1982 to underline a most deplorable infirmity of
> the 2001 Draft:'THE
> PRESENT SITUATION HAS BEEN LARGELY ENGENDERED BY THE ALMOST
9/26/01
1 <
.
Ui O
WHOLESALE
> ADOPTION OF THE HEALTH MANPOWER AND ESTABLISHMENT OF CURATIVE
I
CENTRES
BASED
> ON THE WESTERN MODELS, WHICH ARE INAPPROPRIATE AND IRRELEVANT TO
THE REAL
> NEEDS OF THE PEOPLE AND THE SOCIO-ECONOMIC CONDITIONS OBTAINING IN
THE
> COUNTRY
MEDICAL SERVICES HAS (SIC!) PROVIDED BENEFITS TO THE UPPER
> CRUSTS OF THE SOCIETY, SPECIALLY THOSE LIVING IN URBAN AREAS.... THE
> EXISTING APPROACH, INSTEAD OF IMPROVING AWARENESS AND BUILDING UP
> SELF-RELIANCE, HAS ENHANCED DEPENDENCY AND WEAKENED COMMUNITY'S
CAPACITY
TO
> COPE WITH ITS PROBLEMS.'
> How could the authors of the draft wish away the NHP1982? Did they analyse
> why this policy remained virtually unimplemented? How can they come
forward
> with the 2001 Draft without giving assurance to the people of India that a
> similar fate will not befall on whatever they have said in the Draft?
> IV. LITTLE ANALYSIS OF THE CURRENT SITUATION
> 8. The Report of the Independent Commission on Health in India, the two
> rounds of the National Family Health Survey, the NSS and the NCAER Surveys
> on utilisation of medical care in India and data from the Ninth Five Year
> Plan document and its Mid-Term Appraisal and from its Programme Evaluation
> Organisation, all point to an advanced state of decay of the health
> services in India. At a somewhat lower level, district-wide study of the
> health service system in Thrissur by C K Jagadeesan (HEALTH FOR THE
> MILLIONS, no.2,1997) also presented a very dismal picture in the much •
> adulated State of Kerala. He found that as many as 80 per cent of the
> doctors do not live in the primary health centres of the districts; they
arc
> busy with private practice in nearby towns. Many do not even turn up at
the
> PHC on some days.
> Analysis of the existing state of affairs with a view to finding policy
> options do not find any place in the Draft.
> V. PROSPECTS OF IMPLEMENTING THE PROPOSED POLICY
> 9. The foregoing analysis of the methodology used, experience of the past
> and
> the present situations leads to the very compelling conclusion that the
> implementation of the Policy will meet the same fate as the NHP 1982. It
> will end as a prescription for the status quo. People, including the poor,
> will be forced to fall back on the greedy merchants of the private sector.
9/26/01
i
u oi
> V. A FRAMEWORK FOR STRIVING TOWARDS AN ALTERNATIVE POLICY
>10. Problems of policy formulation and its implementation is rooted in the
> power structure prevailing in the country. It is essentially a political
> question. So the initiative must come from the political level. If the
> political leadership at the state and Union levels muster the strength to
> remedy the situation, a prescription for the malady that afflicts the
health
> service system of the country can be found. I have written a 83-Chapter,
> MOO computer page manuscript entitled: INDIA'S l-ORCO ITIiN PliOPLE AND T1II?
> SICKNESS OE THE PUBLIC HEALTH SERVICE SYSTEM: A PRESCRIPTION FOR THE
MALADY.
> I have published a summary of this work in HEALTH FOR THE MILLIONS
> (nos.4-6,1997). This contains detailsof short term and long term policy
> action that can be taken to remedy the situation.
> Shri Javed Chowdhury
> Ms Sujata Rao
> ------------------------ Yahoo! Groups Sponsor-------------------------- >
> Get your FREE credit report with a FREE CreditCheck
> Monitoring Service trial
> .http://us.click.yahoo.com/MDsVHB/bQ8CAA/ySSFAA/xYTolB/TM
> To unsubscribe from this group, send an email to:
> pharncc-unsubs.cribc@cgroups.com
> Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
9/26/01
FROM : STATE PLANING BOARD
PHONE NO. : 2824802 2424802
Sep.
HeaKhcare Delivery]
L
25 2O01 01:19PM Pl
..(Progriuniiiatic appnnu'h)
Prof.
V' H A |
/>A, /vrv - oil - G ^'5
1.
2.
4.
5.
•
Member.
State Hanning Board
Government of West Bengal.
Last United Front Government at the Centre (1996-98) and all the Chief
Ministers of States attached importance to implementation of Common
Minimum Programme (CMP). This should be the basis of our appioach to
resolve health problem. This should be implemented through decentralise
planning from bottom.
Centrally assisted / aided / sponsored programmes should oe transferred to the
States with freedom resilience of need based application by the State.
West Bengal has fulfilled. 70% of the directives from Union Government
regarding Common Minimum Programme (CMC). Further financial support
from Centre is needed to comply with the remaining needs for both planned and
non-plaimed budget. Recurrent financial aid from Centre is needed to maintain,
the State units instituted under central directive.
West Bengal has introduced democratisation in the functioning of the
department by instituting Advisory Committees, Management Boards and
Visiting Committees optimise the functioning of the units of health sector. The
optimisation will be achieved with the process of involvement of three tier
Panchayat and Nagarpalikas is properly done.
West Bengal Legislative Assembly has introduced Subject Committees to
establish better relation with the peoples representatives and to make
performance of the department transparent and accountable to the people's
representatives.
Creation of District Health Committee (DHG) has been taken up as a process of
decentralisation. It is envisaged that DHC will act in coordination with Sthayee
Samitis ot Zilla Parishad and Panchayat Samitis to maximise the output of health
sector.
6.
For -primary health care, State is giving maximum importance on paramedical
personnel e.g. CHG TBA, M.P.H.W. and their three-tier supervisor.
ROM : STATE PLAN IMG BOARD
, of this Prhnsn- healthcare, a suree, o! the r,.>rt.K»t> ptohh
For opliiT'.isatiori
of the functioning of the health units and personnel th
and a survey c. ..
7.
This requires central financial assistance.
8.
9.
10.
formulate need based planning.
,
• the basis
State should have the liberty to utilise sub-centres, Pl iC and CllCs
of topical need and morbidity, principal programme una-mic .
Prima v health care (PHC) can be achieved i! tl is supported by ptopel
LiondU health service at the Block level. CHCs / rural,Block Hospitals will be
planned to deliver proper secondary health care and part of tertiary health tare
For^strengthening the secondary heal* care. State will modify the outhne given
11.
for CHC (Community Health Centre) according to its own need.
The basic idea will be to offer Secondary health care at the Block / Sub-Division
- secondary
1--------------e can be taken up by
and District levels. Maximum -load- of- the
medical
Block hospitals and rural hospitals. Complicated cases may be treated at State
General and Sub-divisional hospital part, of the tertiary care can be under taken
by District and up graded S.D. Hospitals.
12.
13.
1:
14.
This will improve the function and turn over oi the Centres oi excellence and
that of the Medical colleges. . West Bengal is contemplating to decentralise and
vest such control to the 3 tier Panchayat and the municipalities. For this,
strengthening of the infrastructure has to be provided to these institut: s.
Creation of DHC (District Health Committee) with Sabhadhipati as its
Chairperson is major break through in the process ol devolution of power. State
ultimately desires to devolve such control to the district authorities regarding,
every health activity of the State including all health units.
To implement secondary health care at the Block level part of the tertiary health
care at the sub-division and district level much resources are needed. Some oi
the financial support may be raised from the affluent section directly or through
one other form of insurance. Union Government should also provide some
financial support.
Higher education is a concurrent subject with Centre and State. Medical
education both at the under graduate and post graduate level does not get any
assistance from the Union Government. Whereas for general and other technical
education centre provides reasonable support from institutions like UGC, OST,
-ROM ; .STSTE FLh...... ..
I
■—I
-
USER etc. Support from Central Government tor mcduml educaiion is mr < C
the other hand, each institutions has to pay a heavy amount (Ks.
i tannum to the Medical Council of India (,MC 1 )■ hr opening a ne.v Lounx am.
for inspection MCI charges a heavy amount (1 lakh 75 thousand at picsen .
may be enhanced further) from the Medical Colleges. J his is imposing a giea.
financial burden on the State Government and Universities.
For these reasons private medical colleges are mushrooming and commercial
business is rampart with medical education. In West Bengal there is not a single
private medical college and students are admitted only on the basis or their
merits. Adequate financial help from Central Government is essential to pievent
this business with medical education. This trade on medical education ,ts
destroying the very spirit of medical service. MCI should charge tne
Government run institute reasonable fees for inspection and other activities.
15.
16.
17.
18.
Internationally it is proclaimed that medical education as it is practiced today is
not serving the desired objective. For experimenting integrated people oriented
need based medical education both MCI and Union Government should accept
the new form of medical education proposed by State Planning Board of West
Bengal and help to implement. This type of need based people orients integrated
medical education. West Bengal Government is conducting training cum
orientation of the medical teachers in the perspective of present situation and
preparing them to accept the innovative from community oriented medical
education. Union Government should give financial assistance to this centre.
This will enable the teachers of Eastern Zone to get acquainted with the
innovative type of medical education.
The role of MCI also should be taken into account. The levy it imposes on the
medical college for affiliation, inspection and introduction of new courses is
prohibitive. This is encouraging private medical colleges and retarding the
prospects ofiGovernment medical colleges.
A suwey to obtain relevant intonnation about the functioning of the health
institutes should be done. Surveillance of morbidity pattern is essential for any
future plaiming for this purpose planning Commission should great financial
support to State Planning Board.
A systematic pool of information from all the States is needed to draw up an
acceptable pattern of health, care and medical education. The importance of
icgional variation and objective situations of the States must be considered in the
process of planning and implementation.
FROM : STA’I L i u
19.
20.
21.
22.
23.
24.
Asscssm.t'1'i of the Indian system of medicines io Ik- coiictiiTcnlp underutken
with the central help. The ration parts of these systems shuuid he developed and
be introduced with equal weightage for treatment of diseases.
In some micro survey (Indus Block in district Bankura) it has been noted that
only about 30% of the ailing population receive proper medicare from the
codified medical system. Remaining about 70% get their curative help either
from non-codified health care providers or do not get medicare at all. These non
codified practitioners whether? scientific or not has acquired their skill through
age old traditional practice. They have considerable acceptability in the
community. It will be wise for the planners io take cognizance of them. These
traditional (oral) practitioners should be identified. Their method of treatment
should be noted and scrutinized with respect and if rational can be used as at
least home medicine for simple ailments as a component part of health cultv
India has a rich heritage of folk medicine. This is still being used by targe
section of tribal population Alexanders well-documented publication on Santa’s
medicine requires a meticulous review. These forms of health care may be
utilised if it is formed beneficial.
Similar exercise can. be undertaken with homeopathy and Unani practitioners.
These persons can be rationally utilised as first contact health activists as they
are working within the community.
The drug industry particularly the drugs of indigenous origin and Indian system
have to be rationalised and promoted for its better functioning and use.
The Medical Nemesis of Western Medicine has been commercialized and
getting beyond the reach of common people. Scientific advancement is welcome
but its limitation must pointed out and misuse be prevented.
r
Discussion on Draft National Health Policy at Planning Board, Camac Street, Kolkata
A discussion meeting on draft National Health Policy was organised at Planning Board,
Camac Street, Kolkata on 25th September 2001, where experts from Govt, and Non
Govt. Health Care organisations attended to express their views on the Draft National
Health Policy 2001.
The meeting started at ll-30a.m. with welcome address by Prof. Gouri Pada Dutta,
Member, State Planning Board, Govt, of West Bengal. He said that because of late reach
of the draft policy to the delegates, many could not react on this in time. However,
feedback from Prof. B.Ray Chaudhuri and Prof. Malini Bhattacharya were available. This
was a short notice discussion organised by Planning Board and he appreciated the role of
WBVHA for their support and cooperation in organising this meeting. State has a special
role in health policy formulation and delegates were requested to express their view on
the draft policy.
Prof. G.P.Dutta proposed Prof B. Ray Chaudhury’s name for presiding over the session
and Ms. P.Sen, WBVHA, seconded the same.
Prof. B. Ray Chaudhury, discussed in short on his view on the draft health policy. He
mentioned about the background of the National Health Policy. Shore Committee Report
(1946) was taken as a basis formulation of Health Policy. The first draft NHP was
declared in 1983, probably under compulsion because India was a signatory of Alma-Ata
declaration.
Prof. G.P.Dutta said that Draft policy was sent to state to react on. Today’s discussion
was called only for the specialists of all system of medicines viz. allopathic.
Homeopathy, Unani, etc. Those who have come, if they take a positive initiative then we
can go further. Perfect draft policy could be improved and could be discussed point wise
with recommendations. Indian Medical Association made discussion point by point on
the 1983 draft health policy and recommendations were sent although those were never
taken into consideration.
While reacting on the present draft. Prof. Dutta said that through the indicators like 1MR,
MMR, CBR, one cannot get the proper understanding on the present health scenario,
rather much infonnation should be given on the morbidity pattern, disaster surveillance.
Talking on the quality service delivery, he mentioned about the strengthening the Primary
Health Care services along with the motivation of govt, doctors for public service.
Regarding Budget, he mentioned the present system of budgetary allocation, which is
calculated as 5% more than the last year.
Prof. Malini Bhattacharya mentioned that we could still send our views and
recommendations on draft National Health Policy to centre. It would need some more
time for detailed discussion on it. Since NHP is formulated based on Shore Committee
Report and Alma Ata declaration, do we need any change, if so, where. Due to
globalization, there has been a shift from the policy taken in Alma Ata conference
causing declination of govt, financial assistance. Prof. Bhattacharya recommended that:
Reduction of Govt, assistance mainly affects people suffering from poverty the
number of whom is innumerable. Keeping the charters adopted in Alma Ata
declaration and the health rights of poor people intact, the policy needs to be
reformulated. Keeping in mind about the declination of govt, assistance, a detailed
discussion is required on budget utilisation.
The Central Govt, by its own capabilities has adopted a National Population
Policy without any scope of consultation. It leads to different state governments in
the country to formulate their own policies different from each. Experts attempt to
raise several points of shortcomings and pitfalls of the said policies. Thus it
requires open house discussion of population policy along with national health
policy, as because, one policy is different from the other one.
Among several solutions, there should be one urgent call of the moment is how to
recover the status of primary health centres functioning at different level. There is
a need to integrate ICDS and to strengthen. Through this decentralized system of
health care services, the chances of making preventive health care an acceptable
and glorified. It is difficult to ascertain the well-being of the people unless the
curative health care is integrated with preventive health care. Thus, there is a need
of comprehensive training for para-medical staff and their deployment, the
scarcity of which literally in our country exist more than the qualified doctors. In
the medical education, the issue on the above requires urgent attention and
importance.
The state government should extend its scope of power and administration to
formulate a state health policy though holding seminars with the attendance of
peoples’ representatives and experts.
Prof. P.N.Chowdhury, member of State Planning Board raised the point of lack of clarity
of policy impact on beneficiary population. There should be more about what else to be
done to understand the positive impact. There is a need to understand the psychological
state of medical officers to know why they do not want to go to rural health centres.
Budget should be programme based.
r
Dr. Prabuddha Kr. Ghosh, Ex Vice-President emphasized on the need of incorporation of
socio-economic matter in National Health Policy. He also said that NHP should
incorporate the matter of rural health service, why doctors are unwilling to go, is that
because of infrastructural inadequacy. Preventive health care should be equally given
importance with curative service. He also talked about the integration of alternative
system of medicines.
Prof Pijush Sarkar opined the draft as not a health policy but a medical treatment policy.
Diseases like Tuberculosis, Kala-Azar, etc should be called as social diseases. Hence all
components for control of these diseases should be incorporated in NIIP. Different
system of medicine needs elaborativc discussion. Policy without entitlement is not at ail a
policy.
Few more findings and recommendations came from delegates are as following:
•
•
•
•
•
Alternative system of medicine has very different meaning. This name is wrongly
used by many quacks, unqualified medical practitioners. There should be a legislation
to stop over the all face practice
Innovative need-based medical education can be incorporated in National Health
Policy. Health Workers should have enough training and orientation to serve to the
society - this also needs to be mentioned in NHP.
Mental Health should be concerned both for medical care and social justice. Adequate
budgetary allocation is needed for mental health care. Draft policy needs to be
discussed even at sub divisional level.
NHP should include about health insurance scheme more clearly
NHP should be based on medical education policy, drug policy population policy. It
should include the inter-departmental coordination. National Health Assembly charter
will be helpful in policy formulation.
At the end a steering committee was fformed with following persons who will prepare a
theme paper based on the discussion and recommendations:
1.
2.
3.
4.
5.
6.
7.
8.
Dr. B.Ray Chowdhury, Chairman
Dr. Samir Dasgupta
Dr. Samir Kar
Dr. Basanta
Dr. Rabin Mukherjee
Dr. Kajar Banik
Dr. P.K.Mukhcrjee, representative from ISM
One representative from Unani
It was suggested that there should be a Health Cell in State Planning Board. This will be
discussed on 8U1 October, 2001 at Planning Board Meeting.
nr, Surya Kanta Mishra,
M j n Is t<a r- in-Cha rn 1 tl ’ K m
’■'731 a re i o a n r i«* ya t >.< .-■Viral r> v/*!
v ? rn .i -ju t
• >>’
7 ! '.I,
\r •
n
3 ‘ l J H. r
/ru::*rsS Buildings, Kolkata•
'Dated I
D. O.
A
I have perused the Draft National Health Policy, 2001. 1 feel that this document
should have been discussed at the National Health Council meeting before placing it
before the Union Cabinet as because a part of Health & Family Welfare and Medical
Education is on the concurrent list. However I enclose the comments of the Government
of West Bengal as follows
The introductory portion of the draft has left out the basic concept «mm> definition
of Health as described in Alma Ata declaration , encompassing physical, mental and
social wellbeing of an individual. Moreover, we find that the present document is largely
bon-owed from the World Bank document (World Development Report, 1993),
sometimes even phraseology is also similar.
•
The Draft Health Policy has some good ideas with regard to increasing the
percentage of GDP on health sector expenditure, emphasis on primary health care and
decentralisation. But in the context of policies pursued by Government of India over the
last few years, as a result of liberalisation, globalisation and privatisation in almost all the
sectors, enunciation of the stated objectives are mere pious wishes. Time and again these
policies have led to deprivation of the poor people from health services. The document in
Para 2.4 states “ it has been estimated that less than 20 percent of the population seeks the
OPD services and less than 45 percent avails of the facilities for in-door treatment in
public hospitals. This is despite the fact that most of these patients do not have the means
to make out-of-pocket payments for private health services at the cost of other essential
expenditure for items such as basic nutrition”. This is a direct admission of the fact that
encouraging commodification
the Government is withdrawing from basic health care and
<
of health.
The document fails to examine the basic reasons which led to such a situation in
which the poor people cannot avail of quality health services. The Government of India
time and again has followed the dictates of World Bank, International Monitory Fund and
World Trade Organisation leaving people at the mercy of market forces even in the
important social sector of health and education. No wonder that we have witnessed
increased spread of Kala Azar and Malaria. The document fails to take inter-sectoral view
of health. It is a fact that we cannot view health in isolation from related areas such as
nutrition, water sanitation, environment and housing. The new policies of liberalisation
privatisation and globalisation have led to slowing down of the growth rate, decline in per
capita consumption of cereals, increasing poverty and an adverse impact on health.
With regard to globalisation, the Government of India has meekly surrendered to
forces of globalisation and any talk of “ a national patent regime for the future which,
while being consistent with TRIPS, avails of all opportunities to secure for the country,
under its patent laws, affordable access to the latest medical and other therapeutic
discoveries... the Government will bring to bear its full influence in all international foraUN, WHO, WTO, etc.- to secure commitments on the part of the Nations of the Globe, to
9.
'-’■I
(D. 0. Ko-
'Dated
lighten the restrictive features of TRIPS in its application to the health care sector”, is
contradictory. The concern expressed in this regard about the possible threat to the health
security of the poor as a result of a sharp increase in the prices of drug and vaccines is
like paying lip service to the cause of the poor people.
In Para 2.23, the document itself states “ Global experience has shown that the
introduction of a TRIPS-consistent patent regime for drugs in a developing country,
would result in an increase in the cost of drugs and medical services”. It is amply clear
that for people living below the poverty line, health care and medical research cannot be
left in the hands of private companies and individuals as these are totally guided by
motive to make profit. ’
The health indicators are useful guideline for assessment of the progress and
failure of the health care delivery system. The most important guideline should be the
assessment of morbidity profile i.e. types and frequency of the diseases. Identification of
the vulnerable section of the population, their socio-economic situation and their response
and the method of counteracting it should form a part of policy and programme. It may
be mentioned here that only around 30% of the population has access to the institutional
codified medicine ( as reported by many surveys ). Provision of sophisticated diagnostic
facilities at Primary Health Centres will be a waste. These can be provided at the
secondary level. Even then most of the ailments can be treated by available facilities if
the peoples’ participation and cooperation is assured.
Similarly with regard to decentralisation, which the State of West Bengal has
implemented in letter and spirit, of paramount importance is political will which is
untortunately lacking in many parts of the country and unless this issue is addressed, any
talk of decentralisation will be just a homily.
7 "
'Dated
D. O. 9^p.
In short, we fail to understand how the national health policy proposes to increase
percentage expenditure of GDP, specially on primary health care sector, when the
policies being perused are leading to slowdown of the economic growth rate. Hence, I
urge upon you to reconvene a meeting of the National Health Counsel where these issues
can be discussed as in a federal polity aspirations of the State Governments have to be
reflected.
z
Yours sincerely,
( Dr. Surya Kanta MiThra)
To
Dr. C.P. Thakur,
Minister of Health & Family Welfare,
Government of India, New Delhi.
{
X
The National Health Policy
A. General observation
1. This can not be considered as a policy statement. It is at best an outline of programme to be
implemented in the ensuing year by the union Government.
2. The basis of Health Policy of 1983 was according to the observation and recommendations of
Shore Committee (1946) followed by recommendations of various other Committees
specially Mudaliar Committee and an alternate approach documents by 1CMR, ICSSR 1981
and Union Government.
3. In the draft paper for discussion there is mention about the achievements and failures but no
analysis of the reasons of failure and the cause of limited achievement.
4. National Health Policy of India was declared in 1983, rather under compulsion because India
was a signatory of Alma-Ata declaration. The basis of this NHP was supposed to be Shore
Committee report (1946) and other subsequent reports specially of Mudaliar Committee
(1959) and ICMR ICSSR Report enunciating and 'Alternate Approach' (1981).
5. Many important events have occurred after this statement 'NHP-83'. So formulation of a new
N.H.P. was over due. Only for this reason Draft NHP-2001 is welcome.
6. For drafting any policy for a country like India an exercise analysing the effect of N.H.P. of
83 from the experience of different state giving sufficient time for discussion is not only
rational but an essential obligation on the part of the Union Government. This is essential
because this continent has geographical socio-economic and cultural diversity. The opinion
from the constituent states should have been asked for about its reaction and response,
success and failures in implementation of N11P'83.
7. For this and unnecessary haste the draft is an example of adhocism and supercillicry approach
to an important issue pertaining to the question of life and death of the people.
8. In any policy formulation the conceptual part of the policy is very important. In Alma-Ata the
meaning of good health was clearly defined. Similar view was documented in Bhore
Committee report by pointing out the causes of disease and ill health were basically denial of
social justice to the large section of people. The emphasis on conceptual commitment is
absent jn the pqlicy statement.
9. Necessity of prior consultation with the states can not be over emphasised as health is a State
subject admitted in out Constitution. The importance can be understood from the reports of
Health subject Committee of W.B.L.A. sent to regularly.
10. Introduction in the policy statement is self defeating and confusing. The warning of David
Warner in his book ’ Politics of Primary Health Care' which is responsible for the
unsatisfactory health situation should be borne in mind. The problem of creation of palaces
of disease (5 star Hospitals) at the cost of primary health care should have been categorically
stated.
11. The health indicators arc useful guideline for a assessment of the progress and failure of the
health care delivery system. The most important guideline should be the assessment of
morbidity profile i.e. types and frequency of the diseases. Identification of the vulnerable
section of the population their socio-economic situation and their response and the method
counteracting it should form the part of policy and programme. It may be mentioned here that
only around 30% of the population has access to the institutional codified medicine (as
reported by many surveys).
12. Each state has created a large number of static units which are not functioning. Without
analysing the cause of non-functioning, blame is given on insufficiency of infrastructuie.
Samething is true for assessment of effective use health man care delivery man power of the
Government.
13. A simple analysis will prove that these infrastructures & man power was created from top
down procedure. The recipient and their representatives were least concerned and educated
about public health. On the other hand they were made victims of strong indoctrinisation of
sophisticated diagnostic and therapeutic measure oriented western Medicines. This has
jeopardized the cultural basis of health care and added commercialisation of health care this
is in addition to the politics of dominance of stronger section ol the society, lhe policy
statement has admitted the lack of surveillance but has not outlined how it can be maximized.
14. There is a confession about the paucity of budgetary allocation on Public Health along with
its gradual 8c persistent reduction. It may be mentioned that financial support is important
but more important is conceptual understanding of health care and active participation of
people. It can not be over emphasised that most of primary health need can be looked after by
the people with some rational training and provision of simple input in the form of financial
material, and technical assistance. This will established the objective of delivering peoples
health in peoples hand.
Details observations
1. Objective - a) It is sketch and illusive. There is no reference to the conceptual part outlined
in Alma-Ata declaration, b) No mention about the assessment of existing infrastructure and
the mode of decentralised public health, c) What should be the proportion of the
contribution by private sector and NGOs and the mode of contribution.
2. Fundamental determinates -
a) Financial Resources - Enhancement of Public Health spending by the Central Govt, is
welcome.
It has to be noted that success of public health activities does not depend a
fiscal distribution of Funds but by the active peoples participation.
It appears that the out look is mechanical, bureaucratic & Top down.
Our attitude should be participatory and from below upward.
3. Equity : The entire statement is vague & evasive
a) Strengthening primary health care system depend upon the endeavour to universalisation of
social justice as much as possible as is being endeavored by L.F. Govt, of West Bengal.
Utilisation of existing infrastructure and man power with the help of now 3 tier Panchayct
Systems.
The directive to the states for expenditure on ;Public Health including Family Welfare is only
1/4
of the total budget. The Central grants; arc mostly vertical and directed in a straight
Jacket manner for implementation. There is no mention about the states authority to modify
these projects and programmes according to their own needs.
Medical Education :
In Equity item IV is ill conceived. Most of the Primary Health Care can be performed by
trained paramedics and social activists (para professionals). Institution of short courses in
various forms has failed, in most of the States it has been proved to be ineffectual. Our
Government has accepted and proposed
an innovative need based Medical education
prepared by our teachers in the State medical Teachers' Training Centre. This module has
been accepted by M.C.I. Union Government is sitting on it. Our present Health Minister
endorsed and encouraged it from the beginning. Our present C.M. assured that if centre does
not implement it, we should make it a political issue. Now our Health Minister can raise this
issue in the Central Health Council and press on the Central Health Ministry for its
acceptance. The Union Government should note that introduction of short courses failed in
many states and simply increasing the number of Medical Colleges and production of doctors
will not serve the puipose. Karnataka State is an example.
Medicines :
There is no dearth of drugs as prescribed by WHO. The supply is sometime faulty. The
problem is created by the irrational prescribing habit of the doctors at different level. The
indoctrinisation of pharmaceutical houses place an important role for creation and artificial
scarcity.
This is applicable to the Allopathic drugs. There is no adequate survey or information about
the Medicines of ISM & H in respect to its availability.
The non availability of other facilities for diagnosis and treatment is
i an alibi raised by the
health personnel. This is due to their defective training.
Provision of sophisticated diagnostic facilities at Primary Health Centres will be a waste At
the secondary level it can be provided. Even then most of the ailments can be treated by
available facilities if the peoples participation and cooperation is assured. Convergence of
vertical programmes and co-ordinated effort by Govt, officials social activists, private
professional and MLAs, MP on the management of Health care delivery is will taken and
should be implementated.
Role of States : States should have more liberty in formulating their own policies and
programmes There is uneven situation between states. Within the States there arc regional
variations. The Central programs can only be optimised if states are allowed to implement
according to the need of the State. Maximise different failure to externally aided project
example.
West Bengal is committed to ensure health service through PRI. The statement on
decentralisation should also be enforced on central directives.
Private Sector
Enforcement of Regulatory mechanisms on private sector is welcome but this will become an
utopia unless the regulatory mechanism is well disciplined and committed.
H.R.D.
To enthuse the young Medicos to choose public health will depend upon limiting the
beneficial benefit through clinical practice and its power over political system.
Concept of Public health requires to be redefined according to the Alma Ata declaration and
Bhore Committee Report.
Non-determinant issues
Research - requires redefinition of disease surveillance & response of the people. This is a
very important tool to plan policies and programmes. More allocation of funds for public
health research is needed.
It should be situated in participatory manner at micro level to ensure peoples involvement.
It can be done in Gram Sansad through the leadership of PRI.
Information Education & Communication has to be reinforced at every level, Population
stabilisation has to be linked with women's empowerment and their rightful position of the
Society.
Issue of Globalisation :
Issue & globalisation of health sector is very important. The document has rightly pointed out
the adverse the effect of globalisation and liberalization of health sectors. The Union
Government is expected to take from political decision to prevent - this adverse effect.
Unfortunately the trend is more for privatisation and supply of sophisticated instrument often
unnecessary for health care delivery. It must be emphasised that health need is different in the
developing country as socio-economic situation and morbidity pattern is different from
developed country.
i 'i-oi. Ji. li/A t. Ci DiUU; ju
M.D. (CAL.) F.R.C.P. Ph D. (Edln)
Consultant Nourologlot
Rctildenco :
h'nbn Knllnsh, Flnt-9F,
55/4, Ccllygunge Circulnr Rond,
Cnlcuttfl - 700 019.
Phone : 474-8240
Chambers : 67, Pnrk Street, Cnlcuttn - 700 016.
Phono ^29-7957
Hours : 6 P.M. - 0 p.M. (By Appointment)
Except Sunday
220, Lower Circular Rood, (A.J.C. Boso Rond)
Calcutta - 700 017.
Phone : 247-3100
Hours : 4 P.M.- 5 P.M. (By appointment)
Except Sunday
Dated
Dear
Dr.
Dutta,
Sub:
Health Policy
J
Thank
you
for your letter no.4-21/99-PRC
dated
IO Apri 1
2000,
giving
me an opportunity to offer my
views
in
any
manner I like.
T he
time is too short for putting forward my view point
in
detai 1
however my short comments on the issues are given
be I ova"
.1 . .
P r' r ? a m h 1 i?
o f y o 11 r 1 < tier c a r r i n s
ii
.1 mpr-mnsi or t
11) a t
I nd la has no health policy. Has Govt, of Ind i a s <c r a»> p o d
trie
IM . H. P. .1983 '?
2..
Defere
adopting a new health policy one must
Ijo con —
vine.nd that the bl at. ion a] Health Policy .1983 has out lived its
uti1i ty.
3..
What
prevented attainment of goals set for
2000 A. 0.
faulty
Health Policy or
lack of will in
i m pIementing
the
Pol icy.
4.. Must of
1983.
the
items mentioned
5.. Some important
from your list.
areas
rr-Jatod
by you
to
are covered
fieri 1th
has
in N. H. P .
been
left out
6..
It needs to be cmplu.isised that, no lintel th programme can
be s u c c c? s s f u 1
unless
p r r.« v i s i. on is
mado
for
a p p ro p r i a te
education/training of different categories of
Professionals
and Paraprofessiona 1s involved;
attention is drawn to Mehta
Committee report in this regard.
7. .
I
would suggest that as a preliminary
task
one must
review
the existing N.H.P. to
identify
any shortcoming
re1 ated
to fulfilment of commitments provided in
the
□on
stitution and var-ious declarations related to health and
to
iden tif y
the constraints which could not be surmounted
and
the reason thereof.
8.. In my perception the problem does not lie in the
but in its implementation.
Pol icy
Prof. B. KAY CHAUDHUBI
M.D. (CAL.) F.R.C.P. Ph □. (K<Hn)
Comultant NourologHt
Chnmber, : 67, Pxrk Gtrcot, Cnlcutln - 700 016.
Phone ^29-7957
P.M. (By Appointment)
Routt : G P.M. - 0
Except Sundny
Rond, (AJ O. Bose Rond)
220. Lower Clrculnr
.Calcutta - 700 017.
Reildonce :
rinbft Knllnnh. rinl-OP,
55/4, Dallygunge Clrculnr Rond,
Calcutta - 700 019.
Phone *. 474-8240
phone : 247-3108
Hours : 4 P.M.- 5 P.M. (By Appointment)
Except Sundny
Dated
identification of emerging new
9. . I beg to differ with your
problems.
examined
i?n the
per
_
P 15H.
3 —needs to be
I feel that the N H F
'
and
emerof "welfare state
Govt. connotation
-spective of
'
populations
section
of very rich
i ‘
gence of a relatively small
the gap between rich and poor.
increasing
in the matter o f
Proper orientation of the population
10..
f or
something
' felt need ' is a must if we want to provide
everybody.
is mandatory I or
11.. Provision of safetynet for health care
development of healthy nations.
varying
12..
In
the
prevailing economic disparity and
Sector
the
role
of
Private
educational level of the country
* "
~? indepth thought and
in health has to be determined with more
must be altered.
present casual free for all attitude
<-•----
short an objective
In
strategy adopted need
to draw up a revised
programme.
the
situationi analysis and reviewof
ventures
’ i L_
be undertaken
bef-ere one
to
--health care
policy
in
the
matter
of
|
of my stray thoughts formuI must admit the above* are some
medical education,
long association with
lated duringj my
i
organisations
.
and professional
health care land
-- social
----
Thanking you,
Yours sincerely.
U
0
■V
■A
J* ‘n
'
{
■
;
t’.f
■■
■
■
»
■
■
■
.-r
'
c
5
f ’
■■
.
...
1
■
»
■
i
• ,f“.
:’r>:
Dr. K K Datta
Director
National Institute of Communicable Diseases
22 Sham Nath Marg
Delhi 110 0^4
■I
MallnfBhattacharya
D-4, Staff Quarters,
Jadavpur University
Calcutta-700 032
~ (R) 473-5900
(0)472-0681
Fax 33-473-1484
33-472-0964
Professor of English
Jadavpur University.
Calcutta-700 032, INDIA
Member, State Women’s Commission. West Bengal
Ex-Member of Parliament (Lok Sabha)
15'1 <^01
3^ Lg^-h-
nrJW
.3) ^y^nrr brnJ'Tr
c^'lWy- qpstrrp
I TW?
I (wtstt &.crvw
‘Al#
i^pr^r-
src^'C^
q-^ra- I
TO aw-
^rfTW
6MTor
Ww (w;(- eq w q,lv,.r
"Ifl ^r
J.
(S.y^ qyyrA4i,w
q ftg- w
w-'-w
Ul(?r
'T
:i
uppyrr ,.v wr/„-
. (?f-ry,
1
(
h(?« y,
(Tja^xsYp3'1- 'Wjqn
@ veinrf^r
fi»r ^rn^f^r,
<
•5JT^'^|T2 ^jct- .
------ 1
')cm ^*7^
.
-s
;wr
^'-rn m.
l fef^srp ^TrvT^r
-^3£r JTT
^rrsm-2
--
jppr
g..,,^.
'• I t'l
XB
'
1
_
.
^l^'t '(Ij
..^r -y
y
l?(yr
■
Qi^yy /i.iqp? (q|-»[f>y■ ’ j
g»rrf»r TRflx
r\ \
W
I q3 ;^v
^I n.ff’cp
C'-p vS^2^[2" Jqan
i 2777
■-yT^rjXy (^-|(Xr W2pq ^rV". I
(2) |3rpXJ1^3
3r^w '^7T-
Jrriziip-p^'
hpr 2^4? prf-s^^
*
^£rr77-'
q4
^[5^^rr^-r i.
Purpose of the meeting
1.
National Health Policy is an important document.
For its preparation an organised effort to assemble relevant
m formation about the health and related situation of the
country is essential.
1.2 The policy declaration of 1983 was also done in an ad hoc
manner. Even the members of Laksabha and Rajya Sabha
were not well versed about the draft policy not to spell of
then paiticipation during its formulation.
1.3 Port declaration observations (specially from 1 MA ) had no
impact on the policy matter. The reaction of different states
was not made available. There is also no information whether
the States had any reaction. Even if the States reacted, it was
not known whether the draft was discussed in broader
platform in the Stale.
1.1
2.
2.1
2.2
2.3
New national Health policy draft 2001.
One draft policy was circulated which
contained only
piogrammatic statements. It was casually prepared. There
was even no mention about NHP-1983.
Subsequently another draft policy has been circulated. On
which this discussion is organised.
oVtheNHP^nn? t0 f0rmulate a comprehensive observation
i the NHP-2001 in one workshop or meeting.
Some general observation may be postulated which will be
ie base line ol further discussion particularly with the
Depaitmcnt of Health and Family Welfare.
2.4
Hon'ble MIC, Health & F.W. i
------ ... is a member of Central health
Council. He can take cognition of this discussion and ask for
further exercise lor presentation in the Central Health
Council.
2.5 If fiom this discussion one broad outline of our State Health
Policy can be drawn up then that can be a basis of discussion
with dilfercnt frontal organisation for their consumption and
opinion.
3.
The State Planning Board after deliberating on this
observation may appraise the Department of Health &
Family Welfare about the States reaction.
3.1 Fiom this future planning and programmes can be initiated.
4.
1 loblem of health has now become an International issue.
4.1 Changing Inteinational situation has already heavily
influential the health planning specially of the developing
countries.
4.2 Globalisation and commercialisation of health care, the shift
in the attitude from service to business has converted health
care delivery into an industry.
5.
All of us has to cat properly in this National and International
pleas.
V/
[On Comprehensive Health Plan lor People of West;Beiigal|
Prof Gouri Pada Dulta
— An approach paper for the members of
Strategic Planning Cell
Department of Health & Family Welfare
Government of West Bengal.
Preamble:
'I'o formulate a ’Comprehensive Health Poliey in West Bengal’.
Following points are to be considered;
1]
West Bengal is a State of Indian Union Government. It is not a province. So
any State has a right to formulate its own policy. At the same time it should be in
confirmation with National Policies. State can also point out its areas of difference
and its own modality of implementation.
2]
Internationally a strong debate is going on between Unifactorial
(Technological supremacy) and Multifactorial (Holistic, concurring with Alina Ata
Declaration, emphasizing on Universalisation of social justice).
Conflict between using health care measure as a means of dominance and
commercialisation and Basic Human Right to live and let live as a creative
contributor to society is evident from the inception and stratification of society.
J
*1
3]
Most of the poor countries, like India were colonies of one or other
advanced countries. Their imposition of education and health care system and style
of life has created major division among the people of poor countries. There is not
only conceptual difference and basic contradiction between those who are products
and beneficiaries of the Western system and the million indigent people who are
deprived of these benefits. The privileged elite group is small but powerful. They
are controlling the country. Even their altruistic measures are planned from top and
imposed upon the recipient.
4]
Since optimisation of health care is dependent on rationalization of society;
stronger section preferred to concentrate on deliverance of medicare to mitigate the
felt need of the people. Active people, are needed to run and maintain the society
and the State.
The failure of realizing 'Alma Ata Declaration' — "Health for All" can be
ascribed to the aforesaid analysis. Although there are many other factors for this
malady.
-2Developmcnt & Health:
It is true that comprehensive development of socio-economic factors is very
important for establishment of a healthy society. Food (Nutrition), Shelter, clear
water, education environment (including disposal of human and animal excreta are
preconditions to achieve a healthy life. But this is not all. Decay disease and death
are also component part of life. In addition, there are calamities, caused by nature
and man as a part of development does also contribute. In those circumstances
technical knowledge along with spirit of service and dedication is needed to combat
the crisis. Preparedness and effective planning are needed to overcome the hazards
of development. Conceptualisation of health care, identification of available
resources and capacity building of the society for its maximum utilisation is also
essential.
Health care - conceptual part:
T i
.>i
With this prologue health care may be envisaged as a composite effort of
technical knowledge and dexterity of its application. Skill to develop appropriate
technology using available resources is important. A continuous endeavour to
improve upon the existing situation keeping ecological balance should be a part of
development.
It is also important to ensure that the policy becomes transparent and
participatory one providing active role of the recipient i.e. community as a whole.
i
The wisdom of people coupled with knowledge of the technically equipped
and committed workers is the best method of formulating a rational health care
policy.
What is meant by Health care:
r.
Health care can be divided into (1) Primary (2) Secondary (3) Tertiary
health care.
Traditional Indicators of Health e.g. Health status, including
Anthropocentric values morbidity profile deficiency symptoms work efficiency are
good objective guide. Other indicators like Crude Death Rate, Crude Birth Rate,
Infant Mortality Rate, Child Mortality Rate, Maternal Mortality Rate, Fertility
Index, Immunisation coverage Couple Protection Rate etc. are also good guide to
assess the health situation of a community and State.
This should be coupled with budgetary allocation and even distribution of
financial support. These factors and indicators have limitations as well. In USA,
15% of the GNP is spent on health. Per capita Heath's expenditure is around 6000
' I
-3dollars. Yet around 50 millions of Americans are outside the coverage for health
care delivery. In 'Kerala' the budgetary allocation on health is much less than most
of the States in India, fhe health indicators (as mentioned above) arc the best in
India. Although the morbidity rate is exceedingly high in Kerala. This suggests that
morbidity profile and work efficiency should be an important measure of health
slalus.
Forinulation of llealtli Policy for any State:
a]
b]
c]
d]
'■
e]
!
It will be rational to divide the policy into following parts:
Conceptual part
Identification of existing resources and its utilisation (All codified systems).
Identification of uncodified and unrecognised resources c.g. community
health practices traditional healers folk, medicine, home medicine, even
witch craft.
Optimisation of both these resources after rationalization on unbiased
manner.
With these understanding unleashing a rational health movement in a
participatory manner with the community.
Objective:
To develop a healthy community who will be socially useful.
I]
To assimilate scientific knowledge and technological advancement
II]
interacting and using them with the need and wisdom of people.
To demystify curative medicine and liberate it from commercialisation and
111]
dominance of the privileged group
FORPALNNING:
•
.1
Health care delivery is divided into
A] Primary Health Care
■
For primary health care: Infusion of self-respect and self-confidence in the
community by a dedicated group of worker is needed.
ni
■‘i
*.
t
For primary health care, knowledge about disease and health; education
about health practices as a part of our culture can prevent large part of the illness
and provide elementary medicare.
These may be included in the Continuous Literacy Programme and
School Health Programme with collaboration of Panchayat. food production,
food consumption, food habit (type of food and time of taking food) can be taken
up within these two programmes. This food stability is preconditioned by
availability of food and proper use by the community.
-4Use of clear water, simple health practices of keeping individual body clean,
houses and the neighbourhood area clean, will be extremely helpful in primaly
health care. Not to spit, defecate and urinal extravagantly does not cost any thing.
Such habits can be part of basic education and self-respect. This habit will truly
become second nature.
Similarly physical exercise and many do's and don t will help to achieve
primary health care for the community with little financial involvement, liaincd
Para professionals, peri medical and Para medical persons, if interacts with the
community in a committed fashion miracle can he achieved.
Manpower utilisation:
In the community, there arc following categories of people who arc
connected with health care delivery.
1]
Institutionalized persons dealing with Western medicine, ISM &
Homeopathy. They may be employed by the Governmenti or may be working in
private or corporate bodies or may be self-employed,
self-employed. lhese
I hose arc piofcssional
personnel. The community has some knowledge and information and gicat
expectation from them. They are products and beneficiaries of this present
exploitative system. Most of them indoctrinises the people for irrational treatment
for various reasons.
2]
i
Non institutionalised persons
(a) Improperly trained and educated self-educated (b) completely through
oral doctrine, familial or traditional communication of tiibal and faith
healers. The first category of health care deliverers i.e. healers of
codified systems constitute about 30% and the remaining group
constitute about 70% of the health care activists in one or other form.
I'Or
primary health
l;or primary
health care the second group has to he idcntilicd and he utilised
along with Para professional peri
Para medical personnel for primary
health care. These indigenous people have direct contact with the
community. These can never be ignored, they should be idcntilicd. lheir
mode of treatment should be respectfully understood and analysed.
They should be taken into confidence without disdain. They should be made
conversant about our attitude and can become first line contact persons and
activists for health care. They can he involved specially for various national
and local health programmes as health activists.
-5Objcdivc situnHon:
Study ol morbidity profile by both micro & macro survey reveals that about
70-75 % diseases arc minor ailments. Simple health measures and minimum noninjurious common medicines will be able to relieve most of the patients. At the
same time care has to be taken through training and supervision on these health
activists. It must be assured that the patients arc not bluffed, harassed or mislaid
through ignorance and selfish interest.
A proper training for those health activists can and should be arranged at
micro i.c. Giam Panchayat / Gram Sansad level. It may be started as a pilot project
in some willing district.
Secondary health care
This primary health care should be supported by an well-organised referral
system and secondary health care unit at the proximal situation of the community
where this experimentation of primary health care will be situated.
bj
1
Infrastructural situation: In West Bengal there are 341 CD Blocks. In each Block
according to its geographical situation, two secondary care centres (CIICs as
conceived in our National Health Policy strategy) can be situated.
In West Bengal there arc 8126 sub-centres, 921 PIICs, 248 BP1IC, 98 Rural
Hospitals, 54 State General Hospitals in the rural and semi urban areas.
A rational planning for utilisation of this adequate infrastructure can
properly manage both primary and secondary health care al the proximal level of
the community.
■ i
L
Rationalisation of these centres will minimise the unnecessary expenditure
and reduce the load on higher centres like Sub-divisional, District and teaching
institutions. In those institutions complicated cares of secondary care and majority
of the tertiary care can be usefully treated. The higher centres like Super speciality
units and Medical Colleges will be able to pursue their academic activity better and
perform quality service for complicated case requiring sophisticated tertiary and
Quaternary care.
To implement these programmes two things should be immediately
undertaken.
1]
Making the whole policy and
co in in unity.
programme transparent
to
the
This can Ibe done by information, education and communication through
official (Government) and Non-official (m;
x lass organisations, Voluntary
-6-
z
oigamsation) channels after the policy and programme is adopted. This
memorandum may be used as a baseline paper for discussion. This policy
alter finalisation has to be proposed and propagated repeatedly and in a
wcll-concerlcd manner. There is a counter force of commercial interest by
the stronger section who want to implement Unifactorial approach for their
politics of dominance and profit.
2]
Re-orientation of medical Education and reorientation of training of
1 aia pi ofessional, Peri and Para medical personnel.
The present system of medical education is (a) information imparting and
not pioblem resolving (b) Not need bases or community oriented, (c) It is
not integrated (d) it is teacher centered, not student centered. For this
reasons they are not being properly utilised.
The paramedical teaching and training is
similarly biased for Unifactorial
technical aspect alone and not meant t^
„,Vil the IIVVU
to comply with
need U1
of society.
1 hese educations and trainings are devoid of social responsibilities and
commitment.
For nnplcmentation of health policy active support of health personnel are
reoriented*8
°btained Unless their e(Jucation and teaching are
3J
Rational use of drugs and all diagnostic and therapeutic procedures.
This can be undertaken after the morbidity profile is assessed and thl
priorities arc registered. Assessment of limitations of the investigative
procedures, preparation of essential drug lists along with educating the
prescribers about rational use of drugs and investigation procedures.
Why Natjuijal health policies have failed?
All our national policies are apparently well meaning. Most of them are
implemented in an isolated manner. They are imposed in a top down
manner. The recipients are never fallen into confidence.
An integrated approach taking the socio-economic and cultural aspect of life
in a holistic manner can maximise the service. It is the only measures by
which national programmes can be successful.
Operational procedure:
1. M.I.C can provide leadership by activising the Strategic Planning Cell.
2. Objectives - already postulated
3. Policy be adopted by placing the memoranda in a state level workshop.
-7-
UNICEF may be requested to finance this. Some experts like Dr. Antia, Prof.
Deodhar, Shri Gopal Krinan (Secy. To CM of MP) Dr. Alok Mukherjee, Mr.
Shrinivasan may be invited to attend the workshop.
4. A group of voluntary trainers and implementation experts to be created at State
level (like VTC of Kerala).
5. This group will be responsible to activise the DHCs GPs and Nagar Palikas at
respective level.
Revitalization of different advisory committees at State level Management Boards
and Advisory Committees at different level.
6. Associating this activity with ICDS, Minimum need programme (CHG, TBA
MP HW and their supervisors.
To prepare numerous groups of Para professional (Voluntary) and training of
these activists besides peri and Para medical workers.
7. As pilot projects it can be undertaken in one or two districts in the following
form.
(a) Design surveillance / survey for privatisation of activities.
i] Done by the community with the assistance of proposed expert group,
independently by its own resources.
ii] Assistance from Government and EAP projects should be gainfully utilised.
iii] Fulfillment of National programmes
• Eradication of communicable disease, I B, Leprosy
• ROH, Immunisation programmes
• Geriatrics
• Mental health problems
• Establishment of a trauma centre. Centres for other non-communicable
diseases.
b) Optimise the infrastructure without coercion
c) Involving Panchayat, Voluntary organisations and different mass organisations
across party (political) line.
d) Directive to discuss health in Gram Sansad meeting.
e) Discussion in the frontal organisations.
8. Survey:
Available secondary data be collected and other social activities are noted..
Health Sector Survey - Micro level participatory survey ol
A]
• Infrastructure - Public and private
• Man power assessment and directives of their proper utilisation.
• Units of NGO /Vos be identified and used.
• Private practitioner of all categories will be requested to participate.
Assessment of Morbidity profile and prioritisation of the need.
B]
Immunisation monitoring
CJ
-8-
D]
E]
F]
RCH, Monitoring
School health Programme
Monitoring the activities of MNP.
Eradication of communicable diseases.
9. Creation of a village health registrar and its maintenance by the community.
10. Informalion, Education and communication in a transparent manner to usher in
health movement. It is not demand oriented but constructive basing on sell-ieliancc
and self respect.
i
i
Draft National Health Policy 2001
A response from the Independent Commission on Health in India (ICHI)
The ICHI at a meeting in Delhi on 26 and 27 September 2001 considered the above
draft Policy in depth. An initial response is being submitted to the Ministry of Health &
Family Welfare, Government of India.
The ICHI appreciates the initiative of the Ministry in putting the draft National Health
Policy (NHP) on the web and inviting public response. Given the complexity of the
issue and the diverse situation in different States and Territories, there is need for
deeper study greater use of an evidence base and more participatory dialogue at
different levels before finalization. A three month period till end December 2001 is
suggested.
After introductory comments, the strength and limitations of the draft are outlined,
recognizing that the boundaries between these are hazy.
Introductory Comments:
1.
There is a need for a conceptual, philosophical framework within which the
different strategic elements are developed.
1
2.
Key concepts such as public health, primary health care, equity, etc need to be
defined for clarity and consistency. In this draft policy, these terms are not
understood and the strategy remain weak and superficial.
3.
A brief reference to the NHP 1983 has been made, but not to the Alma Ata
Conference from which it derived. Using a policy process approach there is
need for a brief historical perspective, building from the S...., Shore and
Mudaliar Committee Reports, the Five Year Plan documents and other expert
committee reports. This draft is not a de novo policy but is an updated, revised
policy statement taking stock of earlier goals and objectives, levels of
achievement or non-achievements and an analysis of health gains underlying
reasons for implementation gaps.
4.
There is a need for insulating mechanisms, legal if necessary. So that
implementation of public health policies and programmes and plans of action
are ensured and concerned agencies held accountable.
5.
A bottom up approach should also be used with greater involvement of people,
Panchayati Raj Institutions and civil society, while re-emphasising the
constitutionally mandated role of the state in protecting and promoting the
health of its citizens, particularly of the improvised and increasing their access
to good quality health care.
2
Strength of the Draft NHP 2001:
1.
The commitment to an increased public health investment from the current
0.9% to 2% of GDP with contributions from both Centre and States within a time
frame. However, health financing should be covered in greater detail, identifying
sources of funding, their influence on priority setting, linkage with
conditionalities, utilization, accountability systems with evidence base for new
prescriptions such as user fees, privatization. The essentiality in terms of social
justice, development and human rights for sufficient state funding to address
basic determinants of health, health promotion, prevention and to meet the
creative needs of the poor need to be stressed.
2.
The proposed distribution of financial allocations (55:35:10 ratio) with an
increased proportion going to primary health care is progressive.
3.
The reference to globalization, economic reforms and TRIPS and their negative
impact on health and on increased prices of drugs and health services.
4.
The recognition of the need to increase the pool of trained public health
personnel and to develop a sound disease surveillance system.
Limitations
1.
There is an amnesia about earlier commitments made by the Government of
India to work towards the goal of Health for All by 2000 AD by adopting the
Primary Health Care approach. It ignores the principles and components of the
3
approach with no attention to critical issues of community participation in
decision making, role of community health workers and appropriate technology,
intersectoral coordination and a rational drug poOlicy. There is a lack of focus as
an integrated, comprehensive approach to development of a primary health
care system. There need to be urgently addressed.
2.
Highlighting equity (regional, rural, urban, class, caste/tribe) with data is
important. However, this is not followed through with strategy to overcome the
inequities. Gender issues, particularly from women's perspective is
inadequately addressed.
3.
Basic determinants of health such as food security and nutrition, safe water
supply, sanitation and environmental issues have been wrongly referred to as
non-health issues and the role of the health sector in this regard has been
v
-'•dVXxJ
•
dismissed.
4.
Given that both Centre and States have constituted responsibilities for health,
their policy does not seem to be founded on balanced, mutual collaboration.
The traditional centralizing tendency in health policy continued to prevail,
bypassing the state, setting up autonomous bodies, reducing their role in policy
design, leaving little flexibility to respond to diverse epidemiological and social
needs different levels of development of health systems.
5.
We have been endeavouring through earlier policies to move away from a
doctor, drug driven curative medical model. This needs to be reflected in human
resource development with equal importance given to good quality training and
4
continuing education of the centre health team from community health worker,
paramedical workers and allied health professionals.
6.
Privatization of health services is over emphasized. It will reduce access to care
for the poor, will not necessarily improve quality and will not produce public
health gains. This is especially so when basic minimal public health needs are
A--Q\-*>JLx7 I
not met. Given that we are one of the most privatized health systems, shrinkage
of the state with shift in role from provider to facilitator is helpful.
7.
Health needs of an important and vulnerable groups namely children, have
been left out. Response to the special needs of young children and adolescents
through the ICDS, school health, lifestyle, education and reading those out of
school need to be specifically addressed.
8.
The policy should build on the lessons learnt and analysis gained from earlier
- .MU-—]'1
policies, plan's and programmes. In the absence of this, the prescriptions seem
simplistic in relation to the complexity of the problems. There should be
reference and links to other policies, namely education for health sciences
6
(1989), nutrition (1993), drug policy (198$ and 1994), Medical Council of India
,|
<
Guidelines (1997)
(1997) and elderly (1998), mental health ( ),
disability and the National Population Policy.
Next Steps Suggested are:
1.
Study and consider the following reports:
a)
Report of the Independent Commission on Health in India
5
b)
The Peoples Health Charter, India and States, evolved by the Jan
Swasthya Sabha and the PHA in December 2000, respectively
2.
c)
The Pai Panandikar Report
d)
The Ambani Report
e)
The Dalal Report (post plague)
f)
The Ramalingaswamy Report
9)
The Tata Consultancy Report
Set up a small group of persons from government and other groups, experts
and health activists to redraft the policy.
3.
Use this revised draft for consultation with states, other departments and
agencies with the public and with the Central Council for Health.
4.
Link with other policies referred to earlier.
5.
Link with the preparation of the 10th Five Year Plan Document
6.
Use an evidence base from existing data and study reports.
7.
Complete this participatory process during the next three months and evolve a
more comprehensive integrate^ policy.
$
The Independent Commission on Health in India would be happy to extend its support,
cooperation and services to the Government of India in this endeavour.
6
Wa^iwr^iNM^tritiaue (for those who couldnt download)
Subject: [pha-ncc] NHP critique (for those who couldnt download)
Date: Tue, 25 Sep 2001 18:50:36 -t-0530 (1ST)
From: ctddsf@vsnl. com
To: pha-ncc@yahoogroups.com
<•
Friends,
1 have received a few requests that the drafts relating to our critoque on
the National Health Policy, 2001, be sent in text format. I am appending the
short overall critique, appended to the text of this message. The other two
documents (i.e. (i) document showing portions we $ant deleted and those we
want added, (i.i) the amended NHP200i incorporating our deletions and
addition) in RTF format. It is not possible to send these in text format as
they are fairly long and contain a lot of formatting that is essential to
understand the draft, but would not be retained in text format. My aplogies
lo chose who would be receiving these documents a second cimei
Thanks,
Ami t
Draft NHr,
2GG1
a brief Critique
The National Health Policy draft has finally been released by the Ministry
of Health and Family Welfare, early this month. The draft is available on
the website of the ministry, which says that comments on the draft will be
entertained for a month. We would first like to register our protest
regarding the arbitrary manner in which this policy is sought to be
finalised. The last Health Policy document by the government was released in
1363. We appreciate that in this intervening period developments in the
socio-economic and political spheres, born within and oucside this country,
would necessitate the formulation of a new policy. But one would have
assumed that such a process would involve wide ranging discussions at all
levels. Moreover, as the draft itself repeatedly states, Health is a State
subject as per our Constitution. Yet we have a document foisted upon us that
has been put together by bureaucrats sitting in Nirman Bhawan. From all
accounts the State governments have not been involved in the precess of
drafting, nor has the Central Council of Health and Family Welfare been
consulted (which is che apex body that has representatives from all State
Health Departments). And now, just one month is being provided to give
comments on a policy that is being drafted after 18 years! Moreover, a
policy that one gathers has been at the drafting stage for three years!
CcKiproznise and Contradictions
ine oraxt appears to oe a coiiiproiiiise effort that marries contradictory
concerns. Section 2, cltreo, " Present Scenario" analyses many of the present
initiatives ano tneir deficiencies, some or the conclusions drawn in this
section are premised on correct assumptions. However, many of these
assumntions are icnored or contradicted in the operative part of the draft,
Section 4, titled "policy prescriptions". It appears as though the two have
been drafted by two different sets of individuals. While the draft makes
appropriate references ubsut docentralisuticn, inadequate funds,
non-viability of vertical programmes, inadequate and dysfunctional
infrascructure, etc. in Seccion 2, uhere are either no matching policy
prescriptions in section 4 or these prescriptions are expressed in vague
generalities. Practically the only areas where the draft makes specific
recommendations, are areas that relate to encouragement of the orivate
sector and legitimisation of privatisation of the health care delivery system.
Fund Allocation — Too
tie Too Late
9/26/01 10:04 A
rnha-nccl NHP critique (for those who couldnt download)
in
mu
rnha-nccl NHP critique (for those who couldnt download)
A further perusal of the draft throws up many fundamental concerns. Possibly
the draft is most eloquent where it is silent about certain areas. We shall
return to tHese later, after d4scussi^g what the draft does say. The draft
admits that public health investment has been "comparatively low". What it
docs not admit is that it has, in fact, been abysmally low
one of th©
lowest in the world. Whac it also does not admit is the fact that such
investment as a percentage of total health expenditure is possibly the
lowest in the world - in other words that India has the most privatised
health system in the world! The draft recommends an increase in public
health expenditure from the present 0.9% of GDP to 2.0% in 2010. While any
mention of an intention to increase public expenditure is welcome, ths
quantum suggested is too little and comes too late. It falls far short of
the 5% of GDP that has been a long standing demand of th© health movement.
Moreover the draft projects that public expenditure in 2010 will be 33% of
uotal health expenditure - up from the present 17%. But even 33% is lower
than that of the average of any region in the globe today — in other words
we visualize that India would continue to be one of the most privatised
health system in the world even in 2010! The draft is eloquent on the
inability of states to increase expenditure on health care and laments that
the allocation by states has in fact decreased in the past decade. There is
a veiled attempt to castigate the states for their inability to increase
expenditure. Such insinuations are uncalled for without a detailed analysis
of the manner in which the liberalisation process has shattered the
tinancial stability of states. It is all the more objectionable given the
fact that the formulation of the draft has seen no participation from the
states, where they would have been in a position to record their point of view.
Top ••• Down Prescriptions
The draft, for all the rhetoric on community participation, is replete with
"top down" prescriptions, while aomitting the wastage involved in running
Centrally sponsored and controlled vertical disease control programmes and
envisaging their integration in the decentralised primary health care
system, it goes on to recommend that we would need to retain many of them!
V subsequent ^omru'1 atinns ■Jin the d^aft, especially in the section, on
policy formulations, assumes the continuance of vertical programmes.
Moreover the draft repeatedly assorts that the Centre will continue to plan
all public health programmes. The draft continuously harps on the
availability of expertise with the Centre, to justify strong Central
control. It is not clear where the basis of such assertions lie. On the
other hand the draft is delightfully vague about actual devolution of
responsibility and financial powers to PRIs and relocation of accountability
to appropriate levels of local self-governments. Tn the absence of such
clarity there is the danger of the primary health care system becoming a
Collector driven exercise, that is controlled by.the Centre - thereby
defeating the entire effort at decentralisation.’
Prescriptions for Privatisation
Numerous formulations in the draft, in various forms, clear the way for even
greater privatisation of the health care system. Tn the garb of encouraging
"civil society" organisations the draft talks about a greater role being
provided to NGOs. The draft says, "the NHP will
suggest policy
instruments for implementation of public health programmes through
individuals and institutions of civil society". In our view this consnitures
a veiled attempt to clear the way for sub contracting public health to NGOs.
The draft introduces the concept of user fees, albeit couched in the usual
sugar coating of it being introduced for those who can pay. Global
experience of user fees at any level shows that they serve only one purpose
tc drive cut the peer and the indigent. Any mention of user fees in a
healtlx policy draft is objectionable and untenable. The section tliat
suggests uargetlng of primary neaiuh care for resource allocation needs to
9/26/01 10:11 A
2 of 4
1.
—
be read along with this prescription for introduction of user fees. While
targeting of primary health care is to be welcomed, this should not
constitute an argument for the legitimisation of the government’s retreat
from providing comprehensive and quality secondary and tertiary care. The
draft hints at this possibility in different sections and also hints at
"enccuraging" the private sector to occupy the space that would be left vacant.
'■ .1
The draft talks about using Indian health facilities to attract patients
from other countries. It also suggests that such incomes can be termed
’’deemed exoort’’ and should be exempt from taxes. This formulation draws from
recommendations that the industry has been making and specifically from the
"Policy Framework for Reforms 5.n Health Care", drafted by the prime
Minister’s -Advisory Council on Trade and Industry, headed by Mukesh Ambani
and Kumaramangalam Birla. Such a proposal, termed by many as "health
tourism", will divert our best resources to serve the interests of the
global health market and create islands of brain and resource drain within
the country. It is a proposal that needs to be rejected outright. The draft
also, presumably drawina inspiration from the same report, talks of
encouraging "the setting up of private insurance instruments for increasing
the scope o^
coverage
t^e secordar’y and tertiary sector under private
health insurance packages". Further, there are repeated references in the
druft about "valuable” contributions made by the private sector and the need
co ’’encourage" more su^h contributions, while the draft is repeatedly
critical of the public neaith system (justifiably so) there is not a single
word of criticism of the ills of the private medical care system, though
reference is made to the need to develop regulatory norms.
Importart Corcorns Ignored
Other important concerns arc either ignored or referred to only in passing.
The draft has a four-line section on women’s health, without any specific
proposals being spelt out. Child health is not even afforded a separate
section, and is dealt with through passing references. It is silent on child
nutrition in spite of the shameful fact that a half of children below 5 are
malnourished in India — a dubious distinction that India shares with only
one other country (Bangladesh) in the world.
■st
In the area of medical education the draft talks o^ the need to introduce
postgraduate courses in ’’family medicine”. The long-standing position of the
health movement has been co limit specialisation and reorient undergraduate
education to equip doctors in a manner that they are able to better address
health needs of the common people. Such a purpose cannot be served by just
introducing another specialty called family medicine. The draft betrays a
total lack of u.r'dersta.nding regarding the need to create a medical education
system oriented to the needs of primary care, and instead is steeped in the
bias of urban specialist based health care. On the ether hand it is entirely
silent about the bane of private medical colleges and the need to restrict
ana regulate these institutions.
The section on Research harps on ’’frontier areas” and medical research.
There is no understanding of the necessity to initiate and sustain research
or public health. The^e ■! s no mentj.on of
o^ the necessity to regulate medical
■it-ria in this regard. The impact of TRIPS
research and to develop ethical
u.
1*1 L. d'*uS G*. £>«JGu*lS
impact on drug prices, but there is no
mention of rhe crippling effect of TRITS on medical research.
Eloquent Silence
As mentioned earlier the draft is most eloquent where it is silent. The
draft, very consciously, abjures the words comprehensive and universal
health care. ..In contrast the MH? 1283 had said: "India is committed to
attaining the goal of "Health for All by the Year 2C0C A.D.” through the
universal provision of comprehensive primary health care services”. .The newdraft, thus, repudiates a fundamental concept of the NHP 1983 and the Alma
3 of 4
9/26/01 10:11 A
Fnha-ncrl NTTP critique (for those who conldnt download)
‘5
Ata declaration. It is also conspicuously silent on the village health
worker - the first contact in the primary health care system. In other
words, by its silence, the draft provides a framework for the dismantling of
the whole concept of primary health care, Significant]y, the section on
policy prescriptions in the draft is entirely silent on the content of the
primary health care system.
The draft has nothing substantive to say of rhe population control
programme, which the health movement has long held to constitute a major
drain on primary health care. It repeats the usual sophistry that advances
m public health have been nullified by increase in population. This refrain
contradicts all evidence available across the globe, which show that
population stabilisation follovzs attainment of certain socio-economic
standards and do not precede them.
The drafr is practically silent about pharmaceuticals and their impact on
health care - thereby accepting that it has no role in formulation of the
drua policy. This is even more surorisinq given the fact that a new Drug
Policy is being discussed by the Industry Ministry today, and reports about
^he poi ■’ry havA b^en
1 Ab1 e
sor»e months.
new policy, ?. t ■’s
believed, will reccmmend further relaxation of price and production
soatrols. Arc
to understand that the NHF believes that increased drug
puces and non-avctllability of essential drugs have no impact on the health
sector?
In brief, the draft constitutes a return from Alma Ata, a return to the
concept of centrally directed institution based health care, much of the
pious rhetoHc notw*thstanding. Tf allowed to be enshrined in its present
fem., the NHP can be used as a ted to legitimise privatisation of the
aaczmj. wxi
sector.
j
-------------------- xahooi uroups Sponsor -------Get your FREE credit report with a FREE Creditcheck:
Monitorino Service trial
http://us.click.yahoo.com/MDsVHB/bQ8CAA/ySSFAA/xYTo1B/TM
—>
To unsubscribe from this group, send an email to:
pha-ncc-unsubscribeGegroups.com
Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
iBheaith-i rtf
Name: HEALTH 1 .RTF
J
5
| Type: Plain Text (texi/piam)(
11^ TP , ^pame: NHP_JS~l.KfF
A
4 of 4
:
Type* Plain Text (text/plQir!)!
9/26/01 10:14 Af
- /XlCO G
NATIONAL HEALTH POLICY
f.
* The strengths of the policy draft is the admission of gross insufficiency of funding and a
commitment to reach 8% with central share being 25% of this, (the goal of health
- expenditure reaching 6% of GDP with 2% of this being public health expenditure needs
closer analysis. Or aim should have been for 75 % of health expenditure to be public
health share)AIso a commitment to equitable fund allocation./rhe firm commitment to
close the gap on the creation of PHCs and CHCs and the effort to put in place a norm for
urban areas is also welcome. The setting up of a medical grants commission and the
stress on filling gaps in specialty requirements, the introduction of a specialty of family
medicine, the expansion of public health capabilities and the proposal to use paramedics,
with adequate training in remote areas for curative services are also welcome. So too are
the concerns expressed on geriatrics. Medical research has found largely adequate
emphasis. Also welcome are the proposals on disease surveillance and health statistics.
However, (even after accepting the premise that this document bits nature cannot
comment on socio economic policy or context) the document remains largely a very
vertical, techno centric and fragmented approach to health care/lt first and foremost fails
to understand the need for decentralization and intersectoral coordination and of
strengthening district and panchayat level mechanisms. It fails to see any role for
community participation and is still very much in the mould of a benevolent state and
profession delivering health to a passive populace. Its understanding of disease control
remains a vertical administration driven approach with emphasis on just three or four
diseases -TB, malaria, blindness and HIV A section on child health and another on
nutrition two key dimensions of any policy document are missing. Its understanding of
what ails the medical education and the problems of the private medical sector is too
limited And finally it gives us no assurance that what is*good in it will not go the way of
the assurances of the HFA documents and the NHP-82. These documents were passed
with much fanfare but were subsequently drowned in a conspiracy of silence. The
complete lack of analysis in th NHP-2001 draft of the unfulfilled commitments of the
HFA declaration and the NHP-1982 document suggests that the same problems may
beset this document too. Thus whereas we can be reasonably sure that the concessions
promised to the private sector will materialize we cannot be sure that the commitment to
25% central funding and taking over the supply of essential drugs to all PHCs- easily the
most important promise -will really materialize.
Below we give a para by para comment on the draft, suggesting the various aspects that
need incorporation or change. Note the changes suggested are indicative and are not
drafted as verbatim amendments for incorporation.
[Para
SUGGESTION
REMARKS
1.2
Whereas we can state that there was
considerable progress in establishing a widely
dispersed network of comprehensive primary
health care centers, the other three
The failure to critically assess
what were the process
outcomes and health status
outcomes spelt out in the NHP
! No.
i
i commitments of the NHP-1983 as enunciated
! above were not met. There was no concerted or
, sustained effort to create these health
volunteers and as of date there is neither a
referral system in place, nor any evenly spread
network of specialist and super-specialist
services”, which remain confined to a handful
of large metropolis. We also not that though the
first objective of a widely dispersed network of
comprehensive health centers were established,
they do not provide comprehensive services.
Their services are limited to family planning
and one or two elements of maternal and child
care services.
Box 1 shows that whereas we were able to
attain the targets set for life expectancy, our
crude birth rate aimed for was 21 ( against an
achievement of), the crude death rate was
(against an achievement of 8.7), the IMP target
was 50( against an achievement of 70) and the
maternal mortality rate target is 200 as against
I the achieved level of 480 per one lakh births
'
i 1-3
1.6
2.1
«
1_ £* J — A.
1
document is one serious
limitation of the current draft.
This paragraph is perhaps the
only one that in brief summary
and selectively spells out the
main processes that the NHP1983 aimed for. It is essential
to note that even these brief
features were not attained.
In 1983 after parliament
approved the NHP the
government set targets which
should appear in the box. These
targets were also part of the
commitment to reach Health for
all. One surprising omission in
this preliminary section is the
complete lack of mention of
Health for All initiatives.
Socio-economic policies that
The current socio-economic reforms -both
ensure the minimum
structural adjustment and globalization
provisioning of the basic
processes adversely impact on health as is „
necessities of life to all, and
i evident from reports from all over the world.
growth and development that is
I Even the World Bank the main initiator and
equitable and sustainable are
i sustainer of these reforms concede as much
the key to ensure a better
when the talk of strengthening the health
system to play the role of a safety net to protest quality of life of the people.
The NHP-2001 positions itself
those sections that are hurt during the
as a guide to adminstrative
adjustment process. TheNHP-2001 has to
action and does not recognize
keep these realities in mind when we move
towards strengthening the public health system. the role of politics and political
action. Essentially this is
because of its acceptance of
current socio economic policy.
Most of this paragrah and the
There is also a need to provide for a greater
next are well drafted and
share of resources to the state, sc that state
planning, especially in critical areas like health welcome, such.
care can be effective.
This paragraph is well written and can be
retained as such. Specifically the committment
h
r
to close the gap of 16% in subcenter and PHCs
and 58% in CHCs is welcome._____________
—
2 3.1
Effort to build up the technical and managerial . The center seems to think that
expertise at the state level must be hastened so it is the appropriate site for
that the states are no longer dependent on the
health planning. It must have a
center for such expertise, leaving the center
more modest assessment of its
free to support medical research and to ensure expertise and of its past
minimum quality and standards and to reduce
achievements in this area.
regional inequities.
Many of the states have
adequate expertise and where
they do not have -nothing can
be more urgent in the NHP
than that they acquire such
expertise. ________________
2.3.2.
This understanding of the
limitation of vertical health
programmes in programme
implementation is good
Unfortunately this is not
reflected in the NHP later on__
I 24
The problem of poor quality of services is
The poor utilization is well
compounded my mis match between services
pointed out and even its causes
provided and local priorities and needs. Further are well delineated - but they
the complete absence of community
are not complete.Its not merely
involvement or participation in health
the poor quality of facilties it is
programmes and the lack of local
also the choice of services
accountability undermines the quality of
available and the bureaucratic
services provided.
nature of such services that is
the problem.(for example rude
bahaviour to patients by govt
employees or corruption)._____
r 2.5.1&2.5.2
These may be seen a
contoversial, but we are clearly
in support of it_____________
2.6
Acceptable as such__________
2.7.2
It is observed.... that currently available
The scarcity is certain
avenues of specialization do not provide
disciplines can be removed
enough manpower are in need of rapid
only by increasing specialty
expansion. For rural needs short term training
opportunities. Not by pushing it
to in-service candidates in such specialties
into the undergraduate
maybe required.____________
course...._________________
: 2.12
“A minimum of epidemiological studies as
Though this policy statement is
well and applied and operational research, ”
a move forward in basic
Strengthening basic sciences faculties in the
research it must see the
unversities and building interdisciplinary
linkagebetwen reasech
mission mode projects may also be
achievement and basic S&T
h 1
' emphasized.
j_________________
2 14
Do not limit to certain disease control
programmes and that too as a very limited form
of supporting implementation. Rather one must
articulate it as the Government shall contribute
to strengthening the role of NGOs in their
advocacy role, in community oriented research,
in health education and in securing community
participation and in building local capabilities
for such participation.
2.17
2.18
a section on child heath is needed__________
Medical malpraxis, kick backs for referrals,
unnencessary diagnostics or therapeutics,
inadequate safeguards and ethical standards in
research are some of the areas where ethical
concerns have been rising. Professional bodies
have been slow and inadequate in their
response to these issues.
I 2.23
n4
I
! 2.25
F
capabilityas well as ways of
orgnising research._________ _
The draft mentions NGOs in
future roles only in
implementing programmes.The
emphasis is not on parceling
out this task to them with the
state retreatg.The emphasis
should be on NGOs playing
complementary and refincrcing
roles especaillyins ecuring
community participation
The focus of discussion on
medical ethics must be on such
widespread issues. Gene
manipulation related issues
maybe addressed but not as
central focus..
Impact of globalisation TRIPS is one form in which
globalisation has an adverse
impact but it is not the only
form. It affects also through
loss of livelihoods, roll back of
the state in social sectors like
the pull back on public
distribution system etc.,
The NT IP however recognizes that intersectoral The nature and type of
intersectoral coordination isnot
coordination will have to be established at
recognized.
manv levels. Convergence of these services at
the local level as part of locqal and district
level planning process is essential to reach the
objectives of the NHP and thehealth
department would have to be proactive in
establishing this._________________
A para on nutrition is also essential.
The key buzz- words of the
In describing approach: to add by
past - community participation,
strengthening district and local level planning
on health and so as to match services provided decentralization and inter
with needs and transfer adequate resources and sectoral coordination are
conspicuous by their absence.
capability to this level for ensuring effective
coordinated programme implementation. ______ Gone also is comprehensive
r
I
In the list of specified objectives to include
Child nutrition levels where less than 10% are
undemounshed by 2010.
primary health care as an
objective and key strategy.
There is a general lack of focus
on child health and nutrition.
What is needed is restructuring of
center-state relationships. However
since this is a larger agenda we
welcome this as one form of transfer of
central funds. But not for pushing
centrally designed programmes. The
idea of provisioning of essential drugs
through central funding and
unde writing resources addressing
minimum needs are steps in the right
direction. Such underwriting would be
an adequate way of reaching both
central and state goals. ,
4.1
4.2
This higher percentage on primary
health care would come from a
greater allocation to health and not
from reallocating the already meagre
funded secondary' and tertiary care
centers in the public health system.
The prioritisation of the primary health
care is welcome but should not be a
pulling»back from a strong secondary
and tertiary linkage which is essential
within the public healhtsystem.
4.3
The policy also envisages that
programme implementation be
effected through autonomous bodies
at State and district levels. State
Health Departments would
coordinate with general
administration, elected
representatives of local bodies and
representatives of civil society
through these boards, (note, the
relative distancing is not called for)
The state level autonomous boards are
not objected to. What is objected to is
the notion of distancing from the state
health department. Then who will at the
village level carryout the TB control
work. If it is the ANM and the PHC
then they are very much within the
chain of command of the state heath
department. Though participation of
MP, NGO etc is welcome we must
point out that horizontal integration
requires the state health department to
be effectively employed. Esentially this
para reflects the vertical approach on
three diseases which the world bank has
j prioritsed and made a condition -TB,
Blindness and HIV to which we have
added malaria. In contradiction with
para.2.3.2. the Draft wants these to go
on till the diseases are controlled. This
is a prescription for their "eternal"
continuation.
' 45
4.6.
i 4.7
i 4.9.
4.11
j
____________________________ ———4
The present four and half year course is
Licentitates of Medical Practice
now not toolong a study for much of the
three year course: may be deleted.
college going population. Past
Person working as paramedicals or
experiece shows that they will aspire to I
nurses in rural areas for sometime
get fully qualified and move to urban
where qualified doctors have been
part of the populations going I
1
unwilling to go may be sponsored by areas.Fair
in for these courses. What we have to
,
these areas for further training to
recognize
is
flexible
admission
policies
give minimum curative care.
, especially for rural poor those who
have served and ANMs and nurses,
health volunteers etc.
____________ •
Ideally
PHCs
should
be
under
; Panchayats should be involved in
panchayats. Even if we are not ready
j identifying local health priorities,
for it at least the decentralization should !
! supporting and monitoring the
provision of services by the state and be more effctive. The role envisaged is
as contractors of govt schemes and
i
in programme implementation.
completely misses the understanding of :
local bodies and their role.____________ ;
Medical grants commission- welcome
Accreditation of medical colleges
idea. One fourth on public health and on
and strengthening and broad basing
family
medicine is welcome move.
of medical council to lay this role.
Punishable to run institutions without
proper accreditation and facilities.
Nonns on capitation fees to be
followed
A sub-center for every 1000 families Welcome proposal on urban healthcare
is essential and a dispensary’ or PHC system. But the norms are inadequate.
The general hospital cannot be the
for every 3 0,000,pl us a 30 bedded
secondary level. 30 bedded CHCs are
Community Health Center for a
essential at the level proposed for PHC
population of one lakh. The
government hospital is for the entire now. Such would depressurise good
inpatient care at lower levels.
district or often for the state and not
for the city alone
Center should support the
development of local level modules
instead of centralising message
|_structures. Local priorities and
6.
cultural idioms etc should be
i incorporated
3.2
4 14
: 4.15
4_n
4 17
I 4.22
If concessions including acquisition ; The provision for earning foreign
exchange through such hospitals is not !
of land etc are made for them then
to be part of the national health policy - i
their social commitments like the
though the ministry of commerce can !
provision of a number of beds or
investigative services free should be report on this development. However
rigorously enforced. Especially links we fail to see the need of concessionswith public hospitals to get a certain the can be left to the market forces. Or
part of referred investigations done
the concessions should yield a return.
free can be insisted on.
; The role of NGOs should mention
; advocacy, health education, building
1 community participation and skills,
| experimenting with innovative
I models of service delivery as also a
1 role in implementing disease control
, programmes in select areas where
' there are transient gaps in the public
i health system.
The national disease surveillance
I Response would usually have to be
programme should contribute to dt
organised at the level of the dt. Hence ;
level health management systems.
this must be seen as the primary user to
Similar with health statistics. The
which the system must be geared.
district personnel and fund should be
strengthened accordingly._
Add section on child health________
Add section on nutrition.__________
Same comment as fr section 4,13.2.
1. The role of local planning of health - of drawing up local plans is missing?
2. Food Policy.
3. Why only TB, malaria, HIV, blindness - why not jaundice, why not encephalitis,
why not snake bites,-District level prioritization and planning is still not being
seen
4. 4 12. Add epidemiological research:
5. 4 13 referral linkages with primary centers and government secondary- and tertiary
care centers
6. 4.14 best used in special areas like mental health and remote areas, also as
complementary to govt structure in providing health education, motivational
support, providing community participation. They will not be used to replace or
dilute state role. Funds earmarked in all programmes for such roles.
7. 4.15 Disease surveillance must be integrated into district and PHC level health
planning and programme monitoring systems.
8. 4.16 strengthen district health management with an epidemiologist in each
district.
9. Add after womens health a section on child health as follows:
10. 4.18.1 The medical council functioning shall be strengthened through funds and
providing space for concerned sectons of civil society and government
particpation, even though the dominat role will be played by professionals
11.4.21.1 Mandatory notificationof occupational disorders and sufficient health
education before and whileon the job.
12. 5.2 Waterborne diseases esp gastroenteritis.
C
[Z> / 1-^
V
'^'c
CTO )
DRAFT NATIONAL HEALTH POLICY 2001
Points That Need A Critique
Positive Features
*
Direct, indirect acknowledgement of
/High levels of morbidity and mortality;
-Poor functioning of Public Health Sendees
-Gress under-funding of the Health Services.
Impact of globalization has not been glorified; somewhat critical view of the role of I RIPS
Takes note of higher public health expenditure in other countries; and its impact in health-status.
Recommendation for doubling of central govt, health expenditure by 2010.
Increased proportion of expenditure on primary health care. (55:35:10 formula)
Envisages regulation of private sector.
\/ Envisages improvements in medical education.
xf
Concern about ethics, mental health, family medicine
Negative Features
3
No mention of xMma Ata Declaration and Primary Health Care Approach.
intersectoral linkages seen in determination of health-status and provision of health care seivices.
”
Primary role of water, food, sanitation, environment etc. has been mentioned in the passing, at the
end.
*
Linkage between distorted development and morbidity pattern not recognized.
No mention of
double burden of old and new diseases; epidemiological polarization. Hence no policy to affect
dcieriniiiants of health through an intersectoral approach.
• ^Xo mention of special vulnerability of women due to the triple burden (pregnancy, child care, laboui
in unoi ganized sector.) and the role of patriarchy.
Specific Points
’^y4r! Box I. the achievements have not been compared with the goals for the year 2000, as envisaged in
rhv 19X3 policy.
‘
.
mdicatoi of malnourishrnent has been even mentioned.
- valence oi undernourishment in children, anaemia in women.
No mention of continued high
•
In section 1.5, there is no mention of road-accident deathsfmore than 50,000 deaths per year); a
product of wrong policies about transportation system in India.
•
No critical analysis of overwhelming domination of F.P. programme.
•
No mention of medico-social issues in drug policy. This is despite the tact that in the proposed
‘pharmaceutical policy 2001', there is not even mention of any of the medico social aspect of drug
policy.
•
No mention of the Community Health Worker for First Contact Care. No departure from doctor
centered model of medical care.
f
•
No critique of privatization, of medical colleges.
•
Nothing on restricting ‘cross-practice’.
•
No cognizance of opposition by women’s and health-groups to injectable contraceptives. No changi
in the cun ent unethical policy on this issue.
•
Nothing on gender sensitization of health-care personnel and on health impact of domestic violence.
•
Goals set in Box IV look arbitrary. They are unrealistic in the context of the experience so far.
>jc :jj sjc sjc >;? jk ijc
National Health Policy-2001
A comparison with the People’s Health Charter
Sr.
1.
NHP-2001
The concept of comprehensive primary health : ■ Alina Ata Declaration not mentioned
' care, as envisioned in the Alma Ata
Declaration should form the fundamental basis 4.3 DELIVERY OF NATIONAL PUBLIC HEALTH
. for formulation of all policies related to health PROGRAMMES
i care. The trend towaids fragmentation of
; health delivery programmes through conduct 4.3.1 NHP-2001, envisages a key_rple for the Central
: of a number of vertical programmes should be
Goverrunent in designing national programmes with
reversed. National health programmes be
: integrated witliin the Primary Health Care the active participation of the State Governments.
J system with decentralized planning, decision- Also, the Policy ensures the provisioning of financial
■ making and implementation with the active resources, in addition to technical support, monitoiing
: participation of the community. Focus be : and evaluation at the national level by the Centre.
slutted from bio-medical and individual based ; However, to optimize the utilization of the public
: measures to social, ecological and community ; health infrastructure at the primary level, NHP-2001
based measures.
.
.
. .
envisages the gradual convergence or all health
programmes under a single Held admmisiratjon.
VerticaTprogramrnes for control of major diseases like
TB, Malaria and HIV/AIDS would need to be
continued till moderate levels of prevalence are
. reached. Tire integration of the programmes will bring
about a desirable optimisation of outcomes through a
convergence of all public health inputs. The policy
also envisages that programme implementation be
effected through autonomous bodies at State and
districtJevels. State Health Departments’
; interventions may be limited to the overall monitoring
: of the achievement of programme targets and other
technical aspects. The relative distancing of the
■ programme implementation from the State Health
Departments will give the project team greater
operational flexibility. .Also, the presence of State
Government officials, social activists, private health
professionals and MLAs/MPs on the management
boards of the autonomous bodies will facilitate wellinformed decision-making.
2.
The primary health care insbluiions including ; 4.6 ROLE OF LOCAL SELF-GOVER^E^^^^
trained village health workers, sub-centers, and . LNSTITUTIONS
; tlie PHCs staffed by doctors and the entire :
: range of communty- health tuncneuarie.r, : 4 6 j NHp.2001 lays
emphasis upon the
mcludint’ the 1CDS workei's. be placed under • • ,
.
c ' G- i i.i
t
4. , \
ir
t
implementa non or pubhc health programmes tlirough
the direct administrative and financial control . , G
1 .
1 G;
cf the relevant level Panchayah Raj : local self Government institutions. The structure of
institutions The overall infrastructure of the
national disease control programmes will have
primarv healm care msututions be under the ; specific components for implementation through such
control v! r oncimd-* and Gram Sabhas and : entities. The Policy urges all State Governments to
provisr
: ft- and ;t... e.o.bie secondary and consider decentralizing implementation of the
'
;
ie!
contr^ et
programmes to such Institutions by 2005. In order to
t'C
1'ar^n.ui
piunarilv through ’
J.
w- V.' B / * V.
' 11^- —
referrals from PHCs.
3.
achieve this, financial incentives, over and above the
resources allocated for disease control programmes,
will be provided by the Central Government.
The essential components of primary' care ■ Primary' health care approach not mentioned at all
should be:
“ Village level health care based on Village :
Health Workers selected by the
community' and supported by the Gram :
Sabha / Panchayat and the Government ■
health services which are given regulatory
powers and adequate resource support
Primaiy Health Centers and sub-centers : 4.4 THE STATE OF PUBLIC HEALTH
with adequate staff and supplies wliich : INFRASTRUCTlfRE
prorides quality curative services at the ;...............
primaiy health center level itself with : 4.4 j njM] envisages the kick-starting of the renvil
oc suppo
"
rom re err
ages
prjniary peahh System bv providing some essential
drugs under Central Government funding through the
decentralized health system. It is expected that the
provisioning o, essential drugs at the public health seivice
; centres will create a demand for other professional sendees
: from the local population, which, in turn, will boost the
: general revival bf activities in these service centres. In
■ sum, this initiative under NHP-2001 is launched in the
belief that the creation of a beneficiary7 interest in the
■ public health system, will ensure a more effective
• supervision of the public health personnel, through
community- monitoring, than has been achieved through the
: regular administrative line of control.
A comprehensive structure for Primary' • 4.9 b^BAN HEALTH
Health Care in urban areas based on urban
PHCs. health posts and Community Health 4.9.1 NHP-2001, envisages the setting up of an organised
Workers under the control of local self urban primary’ health care structure. Since the physical
government such as ward committees and features of an urban setting are different from those in the
municipalities.
rural areas, the policy envisages the adoption of
appropriate population norms for the urban public health
infrastructure. The structure conceived under NHP-2001 is
a two-tiered one: the primary centre is seen as the first-tier,
covering a populationofone lakh, with a dispensary
providing OPD facility and essential drugs to enable access
to all the national health programmes; and a second-tier of
the urban health organisation at the level of the
Government general Hospital, where reference is made
from the primary centre. The Policy envisages that the
funding for the urban primary health system will be jointly
borne by the local self-Govemment institutions and State
and Central Governments.
4.9.2 The National Health Policy also envisages the
establishment of fully-equipped ‘hub-spoke’ trauma
care networks in large urban agglomerations to reduce
accident mortality'.
Enhanced content of Primary Health Care
to include all measures which can be
provided at the PHC level even for less
common or non-communicable diseases
(e.g. epilepsy, hypertension, arthritis, pre
eclampsia, skin diseases) and integrated
relevant epidemiological and preventive
measures
4.15 NATIONAL DISEASE SIJRVEILLANCE
Surveillance centers at block level to NETWORK
monitor the local epidemiological situation
and tertiary; care with all speciality- 4.!5.! NHP-2001 envisages the full operationalization of
services, available in every7 district.
. an integrated disease control network from the lowest rung
4.
; of public health administration to the Central Government,
: by7 2005. The programme for setting up this network will
: include components relating to installation of data-base
handling hardware; IT inter-connectivity' between different
: tiers of the network; and, in-house training for data
: collection and interpretation for undertaking timely and
: effective response.
: A comprehensive medical care progranune ' 4.1 FINANCIAL RESOURCES
; financed by the government to the extent of at
• least 5% of our_GNP. of which at least half be : The paucity of public health investment is a stark reality.
: ^sbursed—to—pancJiayati _raj ..institutiQns.^ ■ Given the extremely difficult fiscal position of the State
■ finance primary' level care. This be Governments, the Central Government will have to play a
; accompanied by transfer of responsibilities to : key role in augmeriIihg^5uNrcTi^rtlLinvestm
: PRIs to run major parts of such a programme, :
into account, the gap in health care facilities under NHPalong with measures to enhance capacities of '
2001 it is planned to increase health sector expenditure to 6
PRIs to undertake die tasks involved.
percent ofGDP with 2 percent of GDP being contributed
as pubhchealth investment, by the year 2010. The State
Governments would also need to increase the commitment
to the health sector. In the first phase, by 2005, they would
: be expected to increase the commitment of their resources
to 7 percent of the Budget; and, in the second phasejsy
. 2010, to increase it to 8 percent of theJBudget. With the
: stepping up of the public health investment, the Central
. Government * s contribution would rise to 25 percentTrom
: the existing 15 percent, by 2010. The provisioning of
: higher public health investments will also be contingent
upon the increase in absorptive capacity of the public
: health administration so as to gainfully utilize the funds
4.2 1 To meet the objective of reducing various types of
inequities and imbalances - inter-regional; across the rural
- urban divide; and between economic classes - the most
cost effective method would be to increase the sectoral
outlay in the primary health sector. Such outlets give
access to a vast number of individuals, and also facilitate
prex-entive and early stage curative initiative, which are
cost effective. In recognition of this public health principle,
XHP-2001 envisages an increased allocation of 55 percent
f the total public health investment for the primary health
sector, the secondary and tertiary health sectors being
targctted for 35 percent and 10 percent respectively. NHP2001 projects that the increased aggregate outlays for the
primary health Sector will be utilized for strengthening
existing facilities and opening additional public health
service outlets, consistent with the norms for such
facilities.
5.
The policy of gradual privatisation o
: government medical institutions, though
: mechanisms such as introduction of user fees
: even for the poor, allowing private practice b}
. Government Doctors, giving out PHCs on
. contract, etc. be abandoned forthwith. Failure
to provide appropriate medical care to a citizen
: by public health care institutions be made
■ punishable by law.
6.
A comprehensive need-based human-power 4 5 £X£E2@ING_PUBLIC HEALTH SERVfCES
plan for the health sector be formulated that
addresses the requirement for creation of a
4.5.1 NHP-2001 envisages that, in the context of the
much larger pool of paramedical functionaries
availability and spread of allopathic graduates in their
and basic doctors, in place of (lie present trend
jurisdiction. State Governments would consider the need
towards over-production of personnel trained
in super-specialities. Major portions of for expanding the pool of medical practitioners to include a
undergraduate medical education, nursing as cadre of licentiates of medical practice, as also
v eil as other paramedical training be imparted practitioners of Indian Systems of Medicine and
; in district level medical care institutions, as a Homoeopathy. Simple services/proccdures can be provided
. necessary complement to training provided in by such practitioners even outside their disciplines, as part
medical/mirsing colleges and other training of the basic primary health services in under-served areas.
institutions. No more new medical colleges to : Also, NHP-2001 envisages that the scope of use of
be opened in the private sector. No • Paramedical manpower of allopathic disciplines, in a
commodification of medical education. Steps ' prescribed functional area adjunct to their current
; to eliminate illegal private tuition by teachers ; functions, would klso be examined for meeting simple.
. m medical colleges. At least a year of : : public
public health
health requirements.
requirements. These
These extended
extended areas
areas of
of
. compulsoiy rural posting for undergraduate
:
functioning
of
different
categories
of
medical
manpower
,e
: <i medical,
, nursing
. - and paramedical)-• education
-----------1 • can be permitted, after adequate trainina and subject to the
be
>e made mandatory,
mandatory without which license to ; monitoring of their*perionnance throush professional
practice not be issued. Similarly, three years of : councils.
----: rural posting after post graduation be made *
compulsory-’.
4.5.2 NHP-2001 also recognizes the need for States to
simplify the recruitment procedures and rules for contract
emplox’ment in order to provide trained medical manpower
n under-served areas.
7.
. lhe unbridled and unchecked gro^-th of the 4.13 ROLE OFTHE PR1VATE SFC TOR
commercial private sector be brought to a halt.
- ---------■ medical
X’Srtion’ancTuse
: G3? NHP;2001 ^visages the enactment of suitable
diagnostics, standard fee structur e and i leg^latlons *or relating minimum infrastructure and
periodic prescription audit to be ’ made ! qUaI^y standards by 2003, in clinical
: obligator}’ Legal and social mechanisms be set ; establlslnT,ents/niedical institutions; also, statutory
■ up to ensure obser\’ance of minimum standards i ^ldellnes for the conduct of clinical practice and delivery
by all private hospitals, nursing/mateniity : 01 raed^cal services are to be developed over the same
homes and medical laboratories. Prevalent Per,od- 1 be policy also encourages the setting up of private,
practice of offering commissions for referral to ipsilrane^ instruments for increasing the scope of the^
be made punishable by law. For this purpose a ■ coverage of the secoiidary and tertiary sector under private
: body with statutory powers be constituted,
: wliich has due representation from peoples
; organisations and professional organisations.
health insurance packages.
4.13.2 To capitalize on the comparative cost advantage
enjoyed by domestic health facilities in the secondary and
tertiary sector^.the policy will encourage the supply of
services to patients of foreign origin on payment. The
rendering of such services on payment in foreign exchange
will be treated as \ieemed exports; and will be made
eligible for all fiscal incentives extended to export
earnings.
4.13.3 NHP-2001 envisages the co-option of the non
governmental practitioners in the national disease control
programmes so as to ensure that standard treatment
protocols are followed in their day-to-day practice.
8.
A rational drug policy be formulated that
' ensures development and growth of a self; reliant industry for production of all essential
: drugs at affordable prices and of proper
quality. The policy should, on a priority basis:
n
■
■
■
•
*
■
“
9.
Ban all irrational and hazardous drugs. Set
up effective mechanisms to control the
introduction
of new
drugs
and
formulations as well as periodic review of
currently approved drugs.
Introduce production quotas & price
ceiling for essential drugs
Promote compulsoiy use of genetic names
Regulate advertisements, promotion and
marketing of all medications based on
ethical criteria
Formulate guidelines for use of old and
new vaccines
Control tire activities of the multinational
sector and restrict their presence onlv to
areas where they are willing to bring in
new teclmology
Recommend repeal of tiie new patent act ;
and bring back mechanisms that prevent
creation of monopolies and promote
introduction of new dings al affordable .
prices
Promotion of the public sector in
production of drugs and medical supplies,
moving towards complete self-rehance m
these areas
Medical Research prionties be based on
morbidity and mortality profile of trie . n:
and details regarding the direction intern and
focus of all research pr.'gramr
• •• .->■>
4.13.4 NHP-2001 recognizes the immense potential of use
of mfonnation technology applications in the area of telemedicine in the tertiary health care sectorTThe use of this
technical aid will greatly enhance the capacity for the
professionals to pool their clinical experience.
■ No mention of rationality of drugs here or in the
drug policy
4.23 IMPACT OF GLOBALISATION ON THE
HEALTH SECTOR
4.23.1 NHP-2001 takes into account tire serious
apprehension expressed by several health experts, of
the possible threat to the health security, in the post
TRIPS era, as a result of a sharp increase in the prices
of drugs and vaccines. To protect the citizens of the
country from such a threat, NHP-2001 envisages a
national patent regime for the future which, while
being consistent with TRIPS, avails of all opportunities
to secure for the country, under its patent laws.
aTfordable access to theJatest medical ancTother
therapeutic discoveries. The Policy also sets out that
the Government will bring to bear its full influence in
all international fora - UN, WHO, WTO, etc: - to
secure commitments on the part of the Nations of the
Globe, to lighten the restrictive features of TRIPS in its
application to the health
————- —_—
4 12 MEDICAL RESEARCH
4 2. \11P-2OO1 envisages the increase in Govemmenthind.-J meiho.nl research to a level of 1 nerce.nt of total
. entirely transparent. Adequate government •; funded medical research to a level of 1 percent of total
fimding be provided for such programmes, health spending by 2005; and thereafter, up to 2 percent bv
Ethical guidelines foi research involving : 2010. Domestic medical research would be focused on new
human subjects be drawn up and implemented therapeutic drugs and vaccines for tropical diseases, such
after an open public debate. No further as TB and Malaria, as also the Sub-types of HIV/AIDS
expenmentation, involving human subjects, be prevalent in the country7. Research programmes taken up by
allowed without a proper and legally tenable :
Government in the^e pnow a^is^uld be‘^du^
nrXrhdPPI^Pndte
in a mission mode. Emphasis would also be paid to time. protection. Failure to do so to be punishable .
.
, ,
/c ,
.
U
by law. All unethical research, especially in the : b°T
developmg operattonal
area of contiaceptive research, be stopped ypPllcatlonswould emure cost effective
forthwith. Women (and men) who without ; dissemination of existing / future therapeutic
tlieu consent and knowledge, have been : d™gs/vaccines mthe general population. Private
: subjected to experimentation, especially with • entrepreneurship will be encouraged in the field of medical
. hazardous contraceptive technologies to be : research tor new molecules-Z-va-ecines.
: traced
forthwith
and
appropriately '
compensated.
Exemplary' damages to be
awarded against the institutions (public and :
private sector) involved in such anti-people, :
unethical and illegal practices in the past.
10.
All coercive measures including incentives and
disincentives for limiting family size be ;
abolished. The right of families and women ■
within families in determining tlie number of :
children they want should be recognized. ■
Concurrently, access to safe and affordable :
contraceptive measures be ensured which
provides people, especially women, the ability :
to make an informed choice. All long-term. :
invasive, systemic hazardous contiaceptive :
technologies such as the injectables (NET-EN. ;
• Depo-Provera, etc.), sub-dermal implants
(Norplant) and anti fertility vaccines should be ■
banned from both the public and private sector. '
Urgent measure be initiated to shift to onus of j
contraception away from women and ensure at ;
least equal emphasis on men's responsibility :
for contraception. Facilities for safe abortions
be provided nglit from tlie primary healtli i
■ center level.
11.
: Support be provided to traditional healing • 2.26 ALTERNATIVE SYSTEAIS OF MEDICINE'
systems, including local and home-based :
healing traditions, for systematic research and : 2.26.1 Alternative Systems of Medicine - Ayurveda,
community based evaluation with a view to J
Unani, Sidha and Homoeopathy - provide a significant
developing the knowledge base and use of
supplemental contribution to the health care services in the
: these systems along with modem medicine as :
country7, particularly in the underserved, remote and tribal
: part of a holistic healing perspective.
areeas. The main components of NHP-2001 apply equally
to the alternative systems of medicine. However, the policy
features specific to the alternative systems of medicine will
: be presented as a separate document.
12.
Promotion
of
transparency
and :
decentrahzation in tlie decision making ■
process, i elated to healtli care, at all levels as
well as adherence to tlie principle of nglit to
•
Refer to National Population Policy-2000.
information. Changes in health policies to be ■
: made only after mandatory wider scientific ;
' public debate.
13.
introduction of ecological and social measures :
to check resurgence of communicable diseases. :
Such measures should include:
■
■
14.
Integration of health impact assessment •
into all development proj ects
Decentralized and effective surveillance :
and compulsory notification of prevalent :
diseases like malaria, TB by all health care :
providers, including private practitioners
Reorientation of measures to check :
STDs/AIDS
through
universal
sex ;
education, promoting responsible safe sex
practices, questioning forced disruption •
and displacement and the culture of:
commodification of sex, generating public :
awareness to remove stigma and universal
availability of preventive and curative :
services,
and special attention to ;
empowering women and availability of
gender sensitive services in this regard.
Facilities for early detection and treatment of
non-communicable diseases like diabetes. .
cancers, heart diseases, etc. to be available to :
all at appropriate levels of medical care.
15.
H
9
Women-centered health initiatives that : 4.17 WOMEN/S H EALTl.1
include:
Awareness generation for social change on : 4.17.1 NHP-2001 envisages the identification of specific
issues ot gender and health, tuple work : programmes targeted at women’s health. The policy notes
burden,
gender
discrimination
in :
women, along with other under privileged groups are
upbringing and lite conditions within and : ^igndicantly handicapped due to a disproportionately low
outside the family, preventive and cuiative . access to health care. The various Policy recommendations
measures to deal with health consequences of ^.oooi, in regard to the expansion of primary health
of women's work and violence agamst : sectQr mfrastructur^ wilI facilitate the increased access of
women
women to basic health care. NHP-2001 commits the
complete maternity benefits and child care ;-------------------■
: highest priority of the Central Government to the funding
facilities to be provided in all occupations ;
tlie ; of the identified programmes relating to woman'slieaTth.
employing women, be they in
: Also, the policy recognizes the need to review the staffing.
organized or unorganized sector
on
:
rt°rms of the public health administration to more
Special support structures that focus
ond
,
comprehensively
meet the specific requirements of women.
single, deserted, widowed women
minority women which will include
religious, ethnic and women wath
with a :
different
sexual
orientation
and
commercial sex workers; gender sensitive ;
services to deal with all the health ■
problems
of
women
including
reproductive health, maternal health,
abortion, and infertility
Vigorous public campaign accompanied
by legal and administrative action against
sex selective abortions including female
feticide, infanticide and sex pre-selection
16.
Child centered health initiatives that include:
w
17.
1.
a
18.
19.
20.
A comprehensive child rights code,
adequate
budgetary
allocation
for
universalisation of child care services
An expanded & revitalized 1CDS
progianune. Ensuring adequate support to :
working women to facilitate child care,
especially breast feeding
Comprehensive measures to prevent child ;
abuse, sexual abuse\ prostitution
Educational, economic and legal measures :
to eradicate child labour, accompanied by i
measures to ensure free and compulsory
quality elementary education for all :
children.
Special measures relating to occupational 4.21 OCCUPAT1ONAL HEALTH
and environmental health which focus on:
Banning of hazardous technologies 1T1 : 4.21.1 NHP-200'1 envisages the periodic screening of the
industry and agriculture
health conditions of the workers, particularly for high risk
Worker centered monitoring of working
health disorders associated with their occupation.
conditions with the onus of ensuring a safe •
and secure workplace on the management
Reorienting medical services for early .
detection of occupational disease
Measures to reduce the likelihood of
accidents and injuries in different settings, j
such as traffic and. industrial accidents,
agricultural injuries, etc.
The approach to mental health problems
should take into account the social structure in
India winch makes certain sections like women
more vulnerable to mental health problems.
; Mental Health Measures that promote a shift
away fiom a bio-medical model towaids a
holistic model of mental health. Community
support &. community based management of
mental health problems be promoted. Services
for early detection & integrated management
of mental health problems be integrated with
Primary Health Care and the rights of the
mentally ill and the mentally challenged
persons to be safe guarded.
Measures to promote the health of the elderly
by ensuring economic security, opportunities
: for appropriate employment, sensitive health
care facilities and, when necessary, shelter for
the elderly. Services that cater to the special
needs of people in transit, the homeless,
migratory workers and temporary’ settlement
dwellers
Measures to promote the health of physical’x
and mentally disadvantaged bv focussing on
4.10 MENTAL HEALTH
4.10.1 NHP - 2001 envisages a network of decentralised
mental health sendees for ameliorating the more common
categories of disorders. The programme outline for such a
disease would envisage diagnosis of common disorders by
general duty medical staff and prescription of common
therapeutic drugs.
4.10.2 In regard to mental health institutions for in-door
treatment oi patients, the policy envisages the upgrading of
physical infrastructure of such institutions at Central
Government expense so as to secure the human rights of
this vulnerable segment of society.
: the abilities rather than deficiencies. Promotion
: of measures to integrate them in the
; community writli special support ratlier than
: segregating
them;
ensuring
equitable
opportunities for education, emplopnent and
: special health care including rehabilitative
: measures.
21.
; Effective restriction on industries that promote
' addictions and an unhealthy lifestyle, like
: tobacco, alcohol, pan masala etc., starting witli
i an immediate ban on advertising, sponsorship
: and sale of their products to the young, and
' provision of services for de-addiction.
DRAFT NATIONAL HEALTH POLICY - 2001
1. INTRODUCTORY
1.1 A National Health Policy was last formulated in 1983 and since then, there have been very
marked changes in the determinant factors relating to the health sector. Some of the policy
initiatives outlined in the NHP-1983 have yielded results, while in several other areas, the
outcome has not been as expected.
1.2 The NHP-1983 gave a general exposition of the recommended policies required in the
circumstances then prevailing in the health sector. It laid out the basic philosophy towards the
health sector in the following words: "India is committed to attaining the goal of "Health for All
by the Year 2000 A.D." through the universal provision of comprehensive primary health care
services".The noteworthy initiatives under that policy were :r
i.
A phased, time-bound programme for setting up a well-dispersed network of
comprehensive primary health care services, linked with extension and health education,
designed in the context of the ground reality that elementary health problems can be
resolved by the people themselves;
ii.
Intermediation through ‘Health volunteers’ having appropriate knowledge, simple skills
and requisite technologies;
m.
Establishment of a well-worked out referral system to ensure that patient load at the
higher levels of the hierarchy is not needlessly burdened by those who can be treated at
the decentralized level;
iv.
An integrated net-work of evenly spread speciality and super-speciality services;
encouragement of such facilities through private investments for patients who can pay, so
that the draw on the Government’s facilities is limited to those entitled to free use.
1.3 Government initiatives in the pubic health sector have recorded some noteworthy successes
over time. Smallpox and Guinea Worm Disease have been eradicated from the country; Polio is
on the verge of being eradicated; Leprosy, Kala Azar, and Filariasis can be expected to be
eliminated in the foreseeable future. There has been a substantial moderate drop in the Total
Fertility Rate and Infant Mortality Rate, but these are well below the targets set in the 1983
policy. The limited success of the initiatives taken in the public health field are reflected in the
progressive improvement of many demographic / epidemiological / infrastructural indicators over
time - (Box-I).
Box-1 : Through The Years - 1951-2000Achievements
1951
1981
Target by 2000 jQ000
. ....
Indicator
- ------Demographic Changes
I Life Expectancy
I Crude Birth Rate
I Crude Death Rate
| 54______
4orn 3T9(S^)
25....... | T2?5(SRS)
64
21.0
°H 26.1(99 SRS)
“|'g;7(99 SRS)"
ipMR
146
<60
][70 (99 SRSP
36.7
110
MMR
Epidemiological Shifts
Malaria (cases in million)
Leprosy cases per 10,000
population
Small Pox (no of cases)
Guineaworm (no. of cases)
Polio
Infrastructure
SCZPHC/CHC
75
2.7
573
>44,887
Eradicated
725
I
.. ii
W
2.2
T74
>39,792
29709
Eradicated
___
57,363
1,63,181
(99-RHS)
Dispensaries &Hospitals( all)
9209
23,555
Beds (Pvt & Public)
117,198
569,495
43,322 (95-96CBHI)
8,70,161
(95-96-CBHI)
Doctors( Allopathy)
61,800
2,68,700
5,03,900
(98-99-MCI)
Nursing Personnel
18,054
1,43,887
7,37,000
(99-INC)
1.4 While noting that the public health initiatives over the years have contributed significantly to
the some improvement of these health indicators, it is to be acknowledged that public health
indicators / disease-burden statistics are the outcome of several complementary initiatives under
the wider umbrella of the developmental sector, covering Rural Development, Agriculture, Food
Production, Sanitation, Drinking Water Supply, Education, etc. Despite the impressive limited
public health gains as revealed in the statistics in Box-I, there is no gainsaying the fact that the
morbidity and mortality levels in the country are still unacceptably high. These unsatisfactory
health indices are, in turn, an indication of the limited success of the public health system to meet
the preventive and curative requirements of the general population.
1.5 Out of the communicable diseases, which have persisted over history, incidence of Malaria
has staged a resurgence in the 1980s before stabilising at a fairly high prevalence level during the
1990s. Over the years, an increasing level of insecticide-resistance has developed in the malarial
vectors in many parts of the country, while the incidence of the more deadly P-Falciparum
Malaria has risen to about 50 percent in the country as a whole. In respect of TB, the public
health scenario has not shown any significant decline in the pool of infection amongst the
community, and, there has been a distressing trend in increase of drug resistance in the type of
infection prevailing in the country. A new and extremely virulent communicable disease HIV/AIDS - has emerged on the health scene since the declaration of the NHP-1983. As there is
no existing therapeutic cure-or vaccine for this infection, The disease constitutes a serious threat,
not merely to public health but to economic development in the country. The common water
borne infections - Gastroenteritis, Cholera, and some forms of Hepatitis - continue to contribute
to a high level of morbidity in the population, even though the mortality rate may have been
somewhat moderated. The period after the announcement of NHP-83 has also seen an increase in
mortality through ‘life-style’ diseases- diabetes, cancer and cardiovascular diseases. The increase
in life expectancy has increased the requirement for geriatric care. Similarly, the increasing
burden of trauma cases is also a significant public health problem. To address concerns regarding
the non-attainment of a large number of goals set out in NHP83 as well as the changed
circumstances relating to the health sector of the country since 1983 have generated a situation in
which it is now necessary to review the field, and to formulate a new policy framework as the
National Health Policy-2001.
1.6 NHP-2001 will attempt to set out a new policy framework for the accelerated achievement of
Public health goals in the socio-economic circumstances currently prevailing in the country.
2. CURRENT SCENARIO
2.1 FINANCIAL RESOURCES
The public health investment in the country over the years has been comparatively low one of the
lowest in the world. Worse still, during the period of economic liberalisation in the country, as a
percentage of GDP, it has declined from 1.3 percent in 1990 to 0.9 percent in 1999. The
aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of this, about 20 14
percent of the aggregate expenditure is public health spending, the balance being out-of-pocket
expend!ture. It would not be wrong to say that the system for medical care in the country is the
most privatised system anywhere in the world. The central budgetary allocation for health over
this period, as a percentage of the total Central Budget, has been stagnant at 1.3 percent, while
that in the States has declined from 7.0 percent to 5.5 percent. The current annual per capita
public health expenditure in the country is no more than Rs. 160. Given these statistics, it is no
surprise that the reach and quality of public health services has been well below the desirable
standard. Under the constitutional structure, public health is the responsibility of the States. In
this framework, it has been the expectation that the principal contribution for the funding of
public health services will be from States’ resources, with some supplementary input from
Central resources. In this backdrop, the contribution of Central resources to the overall public
health funding has been limited to about 15 percent. The economic liberalisation programme has
resulted in a major squeeze on the fiscal resources of State Governments. The fiscal resources of
the State Governments are known to be very inelastic. This itself is reflected in the declining
percentage of State resources allocated to the health sector out of the State Budget. If the
decentralized pubic health services in the country are to improve significantly, there is a need for
injection of substantial resources into the health sector from the Central Government Budget, and
a reversal of those elements of economic liberalisation that put a strain on the fiscal resources of
States. This approach, despite the formal Constitutional provision in regard to public health, is a
necessity if the State public health services - a major component of the initiatives in the social
sector - are not to become entirely moribund. The NHP-2001 has been formulated taking into
consideration these ground realities in regard to the availability of resources.
2.2 EQUITY
2.2.1 In the period when centralized planning was accepted as a key instrument of development in
the country, the attainment of an equitable regional distribution was considered one of its major
objectives. Despite this conscious focus in the development process, the statistics given in Box-II
clearly indicate that attainment of health indices have been very uneven across the rural - urban
divide.
Box II : Differentials in Health Status Among States
Population
BPL (%)
Sector
IMR/
Per
1000
^Mort
ality
Weight
For Age-
per 1000
(NFHS
% of
Children
Under 3
years
Live
Births
(1999SRS)
II)
MMR/
Lakh
(Annual
Report
2000)
Leprosy
cases
per
10000
popula
tion
Malaria
+ve Cases
in year
2000 (in
thousands)
(<-2SD)
India
26.1
70
94.9
47
Rural
27.09
75
103.7
49.6
Urban
23.62
44
63.1
38.4
Better
Performing
States
Kerala
12.72
14
18.8
Maharastra
25.02
48
21.12
Low
Performing
States
Orissa
408
3.7
2200
27
87
0.9
5.1
58.1
50
135
3.1
138
52
63.3
37
79
4.1
56
47.15
97
104.4
54
498
7.05
483
Bihar
42.60
63
105.1
54
707
11.83
132
Rajasthan
15.28
81
114.9
51
607
0.8
53
UP
31.15
84
122.5
52
707
4.3
99
MP
37.43
90
137.6
55
498
3.83
528
TN
J
J
Also, the statistics bring out the wide differences between the attainments of health goals in the
better- performing States as compared to the low-performing States. Even within States, there
exist wide disparities because of uneven development. It is clear that national averages of health
indices hide wide disparities in public health facilities and health standards in different parts of
the country. Given a situation in which national averages in respect of most indices are
themselves at unacceptably low levels, the wide inter-State, and intra-state disparities imply that,
for vulnerable sections of society in several States, access to public health services is nominal and
health standards are grossly inadequate. Despite a thrust in the NHP-1983 for making good the
unmet needs of public health services by establishing more public health institutions at a
decentralized level, a large gap in facilities still persists. Applying current norms to the population
projected for the year 2000, it is estimated that the shortfall in the number of SCs/PHCs/CHCs is
of the order of 16 percent. However, this shortage is as high as 58 percent when disaggregated for
CHCs only. The NHP-2001 will need to address itself to making good these deficiencies so as to
narrow the gap between the various States, in backward areas in states, as also the gap across the
rural-urban divide.
2.2.2 Access to, and benefits from, the public health system have been very uneven between the
better-endowed and the more vulnerable sections of society. Vulnerable sections like dalits,
tribals, women, children, women, and the disabled are those who have been the most
marginalised by the uneven reach of the delivery system This is particularly true for women,
children and the socially disadvantaged-sections of socie-tyv The statistics given in Box-Ill
highlight the handicap suffered in the health sector on account of socio-economic inequity.
Box-Ill : Differentials in Health status Among Socio-Economic Groups
Indicator
Infant
Mortality/1000
Under 5
Mortality/1000
% Children
Underweight
India
70
94.9
47
Social Inequity
Scheduled Castes
83
119.3
53.5
Scheduled Tribes
84.2
126.6
55.9
Other Disadvantaged
76
103.1
47.3
Others
61.8
82.6
41.1
2.2.3 It is a principal objective of NHP-2001 to evolve a policy structure which reduces these
inequities and allows the disadvantaged sections of society a fairer access to public health
services.
2.3 DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
2.3.1 It is self-evident that in a country as large as India, which has a wide variety of socio
economic settings, national health programmes have to be designed with enough flexibility to
permit the State public health administrations to craft their own programme package according to
their needs. Also, the implementation of the national health programme can only be carried out
through the State Governments’ decentralized public health machinery. Since, for various
considerations, the-responsibility of-the Central Government in funding additional-public health
services will continue over-a-period of time, the-role of the Central Government in designing
broad-based public health initiatives will inevitably continue. Moreover, it has been observed that
the technical and managerial-expertise for designing large span public health- programmes-exi-sts
with the Central Government in a considerable degree; this expertise can be gainfully utilized in
designing national health programmes for implementation in varying socio-economic settings-m
the statefr-lt is envisaged that the States will have the primary responsibility of designing and
monitoring their health programmes. The Centre will play a co-ordinating role and provide
technical and financial support wherever it is felt necessary.
2.3.2 Over the last decade or so, the Government has relied upon a ‘vertical’ implementational
structure for the major disease control programmes. Through-thisr-the- system has been able to
make a substantial dent in reducing the burden of specific diseases. However, such an
organizational structure, which requires independent manpower for each disease programme, is
extremely expensive, has a low cost-benefit ratio and is difficult to sustain. In the long run it is a
more sustainable option to integrate disease control startegies within the decentralised primary
health care network, linked to adequate secondary and tertiary support services. Over a long time
range, "vertical’ structures may only be affordable for-diseases—which offer-a-reasonablc
possibility of elimination or eradication in a foreseeable time-epan. Vertical programmes may be
considered only as short-term measures, run in a "mission mode" in ver exceptional
circumstances. In this background, the NHP-2001 attempts to define the role of the Central
Government and the State Governments in the public health sector of the country.
2.4 THE STATE OF PUBLIC HEALTH INFRA STRUCTURE
2.4.1 The delineation of NHP-2001 would be required to be based on an objective assessment of
the quality and efficiency of the existing public health machinery in the field. It would detract
from the quality of the exercise if, while framing a new policy, it is not acknowledged that the
existing public health infrastructure is far from satisfactory. For the out-door medical facilities in
existence, funding is generally insufficient; the presence of medical and para-medical personnel is
often much less than required by the prescribed norms; the availability of consumables is
frequently negligible; the equipment in many public hospitals is often obsolescent and unusable;
and the buildings are in a dilapidated state or non-existent in a large number of cases. In the in
door treatment facilities, again, the equipment is often obsolescent; the availability of essential
drugs is minimal; the capacity of the facilities is grossly inadequate, which leads to over
crowding, and consequentially to a steep deterioration in the quality of the services. As a result of
such inadequate public health facilities, it has been estimated that less than 20 percent of the
population seeks the OPD services and less than 45 percent avails of the facilities for in-door
treatment in public hospitals. This is despite the fact that most of these patients do not have the
means to make out-of-pocket payments for private health services except at the cost of other
essential expenditure for items such as basic nutrition.
2.5 EXTENDING PUBLIC HEALTH SERVICES
2.5.1 While in the country generally there is a shortage of medical manpower, this shortfall is
disproportionately impacted on the less-developed and rural areas. Further, such shortage is most
acute in the case of para-medical manpower like nurses, health workers and technicians. Because
of low returns, private medical manpower seldom ventures into underserved areas. Even in the
public health sector, it has been difficult to deploy and retain medical manpower in these areas
because of the harsh circumstances that obtain here, including lack of access to even very basic
facilities. No incentive system attempted so far, has induced private medical manpower to go to
such areas; and, even in the public health sector-it has usually been a Iosing-battle-t-e-depley
medical manpower in such under served areas. Only a radical transformation of publicly funded
facilities in less developed areas will facilitate the retention of medical humanpower in these
areas. Alongside this, a large number of public health functions can be entrusted to adequately
trained and suitable remunerated para-medical personnel, including village level health workers.
The first contact in the Primary Health Care system, through trained village health workers
chosen by the community, as envisaged in the NHP83, needs to be strengthened after analysing
the earlier weaknesses in the VHW scheme. In such a situation, the possibility needs to-be
examined for entrusting some limited public health functions to nurses, paramedics and other
personnel from the extended health sector after imparting adequate training to them.
2.5.2 India has a vast reservoir of practitioners in the Indian Systems of Medicine and
Homoeopathy, who have undergone formal training in their own disciplines. The possibility of
using such practitioners in the implementation of State/Central Government public health
Programmes, in order to increase the reach of basic health care in the country, is addressed in the
NHP-2001.
2.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS
2.6.1 Some States have adopted a policy of devolving programmes and funds in the health sector
through different levels of the Panchayati Raj Institutions. Generally, the experience has been a
favourable one. The adoption of such an organisational structure has enabled need-based
allocation of resources and closer supervision through the elected representatives. NHP- 2001
examines the need for a wider adoption of this mode of delivery of health services, in rural as
well as urban areas, in other parts of the country.
2.7 MEDICAL EDUCATION
2.7.1 Medical Colleges are not evenly spread across various parts of the country. Apart from the
uneven geographical distribution of medical institutions, the quality of education is highly uneven
and in several instances even sub-standard. It is a common perception that the syllabus is
excessively theoritical, making it difficult for the fresh graduate to effectively meet even the
primary health care needs of the population. There is an understandable reluctance on the part of
graduate doctors to serve in areas distant from their native place. NHP-2001 will suggest policy
initiatives to rectify these disparities.
2.7.2 Certain medical discipline, such as, molecular biology and gene-manipulation, have become
relevant in the period after the formulation of the previous National Health Policy. Also, certain
speciality disciplines - Anesthesiology, Radiology and Forensic Medicines - are currently very
scarce, resulting in critical deficiencies in the package of available public health services. The
components of medical research in the recent years have changed radically. In the foreseeable
future such research will also rely increasingly on such new disciplines. It is observed that the
current under-graduate medical syllabus does not cover such emerging subjects. NHP-2001 will
make appropriate recommendations in this regard.
2.7.3. There has been a mushrooming a private medical colleges in the country. There is a need to
standardise minimum norms regarding facilities that should be available at such institutions.
There is also the need to standardise fee structures in such institutions. Many State governments
are giving permission to start new private medical colleges withour regard to such norms and
standards. The NHP2001 issues guidelines in this regard.
2.8 NEED FOR SPECIALISTS IN PUBLIC HEALTH’ AND ‘FAMILY MEDICINE’
2.8.1 In any developing country with inadequate availability of health services, the requirement of
expertise in the areas of ‘public health’ and ‘family medicine’ is very much more than the
expertise required for other specialized clinical disciplines. In India, the situation is that public
health expertise is non-existent in the private health sector, and far short of requirement in the
public health sector. Also, the current curriculum in the graduate / post-graduate courses is
outdated and unrelated to contemporary community needs. In respect of ‘family medicine’, it
needs to be noted that the more talented medical graduates generally seek specialization in
clinical disciplines, while the remaining go into general practice. While the availability of
postgraduate educational facilities is 50 percent of the total number of the qualifying graduates
each year, and can be considered more than adequate, the distribution of the disciplines in the
I
postgraduate training facilities is overwhelmingly in favour of clinical specializations. NHP 2001
suggests ways to reorient undergraduate courses in order to equip medical graduates adequately
to face the challenges of primary care and family medicine. Such reorientation will seek to ensure
that the current craze for specialisation is reversed and more graduates take up primary care as a
long term vocation. In order to address possible "academic stagnation" among such graduates and
to ensure adequate availability of trained humanpower in "public health" and "family medicine",
NHP 2001 makes recommendations for creating and expanding the scope for specialisation in
"public health" and "family medicine". NHP-2001 examines the need-for-ensuHng adequate
availability ofpersonnel with specialization in the "public health’ and ‘family medicine^
disciplines, to discharge the public health responsibilities in the country.
2.9 URBAN HEALTH
2.9.1 In most urban areas, public health services are very meagre. To the extent that such services
exist, there is no uniform organisational structure. The urban population in the country is
presently as high as 30 percent and is likely to go up to around 33 percent by 2010. The bulk of
the increase is likely to take place through migration, resulting in slums without any infrastructure
support. Even the meagre public health services available do not percolate to such unplanned
habitations, forcing people to avail of private health care through out-of-pocket expenditure. The
rising vehicle density in large urban agglomerations has also led to an increased number of
serious accidents requiring treatment in well-equipped trauma centres. NHP-2001 will address
itself to the need for providing this unserved population a minimum standard of health care
facilities.
2.10 MENTAL HEALTH
2.10.1 Mental health disorders are actually much more prevalent than are visible on the surface.
While such disorders do not contribute significantly to mortality, they have a serious bearing on
the quality of life of the affected persons and their families. Serious cases of mental disorder
require hospitalization and treatment under trained supervision. Mental health institutions are
perceived to be woefully deficient in physical infrastructure and trained manpower. NHP-2001
will address itself to these deficiencies in the public health sector. As recent events have shown,
private institutions providing mental health care are grossly negligent and lack basic facilities.
The NHP2001 will suggest ways to monitor and regulate such facilities.
2.11 INFORMATION, EDUCATION AND COMMUNICATION
2.11.1 A substantial component of primary health care consists of initiatives for disseminating, to
the citizenry, public health-related information. Public health programmes, particularly, need high
visibility at the decentralized level in order to enhance their have-any impact. This task is
particularly difficult as 35 percent of our country’s population is illiterate. The present IEC
strategy is too fragmented, relies heavily on mass media and does not address the needs of this
segment of the population. It is often felt that the effectiveness of IEC programmes is difficult to
judge; and consequently, it is often asserted that accountability, in regard to the productive use of
such funds, is doubtful. NHP-2001, while projecting an IEC strategy, will fully address the
inherent problems encountered in any IEC programme designed for improving awareness in order
to bring about behavioural change in the general population.
2.11.2 It is widely accepted that school and college students are the most receptive targets for
imparting information relating to basic principles of preventive health care. NHP-2001 will
attempt to target this group to improve the general level of health awareness.
2.12 MEDICAL HEALTH RESEARCH
2.12.1 Over the years, medical research activity in the country has been very limited and has been
limited to medical research. In the Government, such research has been confined to the research
institutions under the Indian Council of Medical Research, and other institutions funded by the
States/Central Government. Research in the private sector has assumed some significance only in
the last decade. In our country, where the aggregate annual health expenditure is of the order of
Rs. 80,000 crores, the expenditure in 1998-99 on research, both public and private sectors, was
only of the order of Rs. 1150 crores. It would be reasonable to infer that with such low research
expenditure, it would be virtually impossible to make any dramatic break-through within the
country, by way of new molecules and vaccines; also, without a minimal back-up of applied and
operational research, it would be difficult to assess and modulate the direction of whether the
health expenditure in the country is being incurred through optimal applications and appropriate
public health strategies. The NHP 2001 will encourage greatly enhanced public investment in
research, which, as global experience has shown, is an imperative for giving a thrust to research;
while at the same time offering incentives to the private sector to enage in appropriate and
relevant research. Medial Health Research in the country needs to be focused, first, on
optimisation of public health strategies, and also on therapeutic drugs/vaccines development for
tropical diseases, which are normally neglected by international pharmaceutical companies on
account of limited profitability potential. The thrust will need to be on, both, research on
problems of public health, and basic research on development of medical appliances like drugs,
vaccines and diagnostic aids. Research activities will also need to focus on the newly-emerging
frontier areas of research based on genetics, genome-based drug and vaccine development,
molecular biology, etc. NHP 2001 will also address the issue of ethics in medical research,
especially keeping in view recent reports of violation of ethical norms even in public sector
research institutions. It shall recommend setting up of suitable mechanisms, institutional and
legal, for the regulation and monitoring of medical research in both the public and private sector.
NHP-2001 will address these inadequacies and spell out a minimal quantum of expenditure for
the coming decade, looking to the national needs and the capacity of the research institutions to
absorb the funds.
2.13 ROLE OF THE PRIVATE SECTOR
2.13.1 Considering the economicrestructuring underway in the country, and over the globe, since
the last decade, the changing role of the private sector in providing health care will also have to
be addressed in NHP 2001. At present the private sector is the largest unregulated sector enaged
in commercial activities, and the issue of its regulation will be addressed by the NHP2001.
Currently, the contribution of private health care is principally through independent practitioners.
Also, The private sector contributes significantly to secondary-level care and some tertiary care.
Given its large reach and unregulated character. With the increasing role of private health care,
the need for statutory licensing and monitoring of minimum standards of diagnostic centres /
medical institutions becomes imperative. NHP-2001 will address the issues regarding the
establishment of a regulatory mechanism to ensure adequate standards of diagnostic centres /
medical institutions, conduct of clinical practice and delivery of medical services.
2.13.2 Currently, non-Govemmental service providers are treating a large number of patients at
the primary level for major diseases. However, the treatment regimens followed are diverse and
not scientifically optimal, leading to an increase in the incidence of drug resistance. NHP-2001
will address itself to recommending arrangements, which will eliminate the risks arising from
inappropriate treatment.
2.13.3 The increasing spread of information technology raises the possibility of its adoption in the
health sector. Its role in information dissemination, monitoring and surveillance, which have a
bearing on concerns related to public health, will be examined by NHP 2001. NHP 2001 will
examine this possibility, especially in the areas oTv
2.14 ROLE OF THE CIVIL SOCIETY
2.14.1 Historically, the practice has been to implement programmes for primary health care and
major national disease control programmes through the public health machinery of the
State/Central Governments. It has become increasingly apparent that NGQs and other civil
society organisations can play an important role in the monitoring of such programmes and in
increasing participation of local communities in planning and implementation of such
programmes. They have also played a major role in community mobilisation, that is often a major
component of any public health programme, certain components of-such programmes cannot be
efficiently implemented merely through government functionaries. A considerable change in the
mode of implementation-has come about in the last two decades,-with an increasing involvement
of NGOs-and other institutions of civil society. It is to be recognized that widespread debate on
various public health issues have, in fact, been initiated and sustained by NGOs and other
members of the civil society. Also, an increasing contribution is being made by such institutions,
in the delivery of different components of public health-services. Certain disease-control
programmes require close inter-action with the benefiei-aries for regular administration of drugs:
periodic carrying out of the pathological tests; dissemination of information regarding disease
control and other general health information. NHP-2001 will address such issues and suggest
policy instruments for involvement of civil society institutions in the monitoring of public health
programmes implementation of-public health programmes through individuals and institutions of
civil society.
2.15 NATIONAL DISEASE SURVEILLANCE NETWORK
2.15.1 The technical network available in the country for disease surveillance is extremely
rudimentary and to the extent that the system exists, it extends only up to the district level.
Disease statistics are not flowing through an integrated network from the decentralized public
health facilities to the State/Central Government health administration. Such an arrangement only
provides belated information, which, at best, serves a limited statistical purpose. The absence of
an efficient disease surveillance network is a major handicap in providing a prompt and cost
effective health care system. The efficient disease surveillance-network set up for Polio and
HIV/AIDS has demonstrated the enormous value of such a public health instrument. Real-time
information of focal outbreaks of common communicable diseases - Malaria, GE, Cholera and JE
- and other seasonal trends of diseases, would enable timely intervention, resulting in the
containment of any possible epidemic. In order to be able to use an integrated disease surveillance
network, for operational purposes, real-time information is necessary at all levels of the health
administration. NHP-2001 would address itself to this major systemic shortcoming in the
administration.
2.16 HEALTH STATISTICS
2.16.1 The absence of a systematic and scientific health statistics data-base is a major deficiency
in the current scenario. The health statistics collected are not the product of a rigorous
methodology. Statistics available from different parts of the country, in respect of major diseases,
are often not obtained in a manner which make aggregation possible, or meaningful.
2.16.2 Further, absence of proper and systematic documentation of the various financial resources
used in the health sector is another lacunae witnessed in the existing scenario. This makes it
difficult to understand trends and levels of health spending by private and public providers of
health care in the country, and to address related policy issues and formulate future investment
policies.
2.16.3 NHP-2001 will address itself to the programme for putting in place a modem and scientific
health statistics database as well as a system of national health accounts.
2.17 WOMEN S HEALTH
2.17.1 Social, cultural and economic factors continue to inhibit women from gaining adequate
access to even the existing public health facilities. This handicap does-not just affect women as
individuals; it also has an adverse impact on the health, general well-being and development of
the entire family, particularly children. NHP 2001 recognises The catalytic role of empowered
women in improving the overall health standards of the community also needs to be recognised.
The NHP2001, recgnising that issues related to women's health are not confined to their role in
child bearing or to problems related to the reproductive tract, sets out policy guidelines that are
aimed at enabling women to access the health care system in much larger numbers.
CHILD HEALTH
Children — who are naturally vulnerable — face a large brunt of problems that relate to the
inadequate reach of public health facilities and services. The are more likely to fall prey to
infectious diseases, and infant and child mortality rates continue to be unacceptable high. In fact
in the last few years the disturbing trend of stagnation or reversal of fall in such mortality rates
have been reported. The problem of undemutrition, further, is a very serious problem among
children, given that more than half of children under the age of five are malnourished. This is a
shameful statistic and is a record that is the worst in the world with the exception of Bangladesh.
The NHP2001, taking serious note of these issues, recommends specific child centred initiatives.
2.18 MEDICAL ETHICS
2.18.1 Professional medical ethics in the health sector is an area, which has not received much
attention in the past. Also, the new frontier areas of research - involving gene manipulation,
organ/human cloning and stem cell research — impinge on visceral issues relating to the sanctity
of human life and the moral dilemma of human intervention in the designing of life forms.
Besides these, in the emerging areas of research, there is an uncharted risk of creating new life
forms, which may irreversibly damage the environment, as it exists today. NHP - 2001
recognises that moral and religious dilemma of this nature, which was not relevant even two years
ago, now pervades mainstream health sector issues.
ENSURING ACCESS TO ESSENTIAL DRUGS, AND RATIONAL DRUG USE
Universal access to life saving medicines is a major imperative for the success of medical
interventions. We have had the unfortunate precedent of the National Drug Policy being
formulated by the Industry Ministry, with insignificant inputs from the Ministry of Health. The
promise in the 1995 Drug policy to set up a National Drug Authority that would, among other
things, co-ordinate between the two ministries in formulation and implementation of the country's
Drug Policy was never implemented with seriousness. Many elements of the Drug policy like
pricing, control on irrational and hazardous drugs, promotion of medicines, self reliance in drug
production, etc, have a bearing on access to drugs. Considering these the NHP2001 suggests that
the nation's drug policy will reflect adequately concerns related to rational and affordable medical
care, and to this end suggest guidelines.
2.19 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DRUGS
2.19.1 There is an increasing expectation and need of the citizenry for efficient enforcement of
reasonable quality standards for food and drugs. Recognizing this need, NHP - 2001 makes an
appropriate policy recommendation.
2.20 REGULATION OF STANDARDS IN PARA MEDICAL DISCIPLINES
2.20.1 It has been observed that a large number of training institutions have mushroomed
particularly in the private sector, for several para medical disciplines - Lab Technicians, Radio
Diagnosis Technicians, Physiotherapists, etc. Currently, there is no regulation/monitormg of the
curriculum, or the performance of the practitioners in these disciplines. NHP-2001 will make
recommendations to ensure standardization of training and monitoring of performance.
2.21 OCCUPATIONAL HEALTH
2.21.1 Work conditions in several sectors of employment in the country are sub-standard. As a
result of this, workers engaged in such activities become particularly prone to occupation-linked
ailments. The long-term risk of chronic morbidity is particularly marked in the case of child
labour. NHP-2001 will address the risk faced by this particularly vulnerable section of the
society.
2.22 PROVIDING MEDICAL FACILITIES TO USERS FROM OVERSEAS
2.22.1 The secondary and tertiary facilities available in the country are of good quality and costeffective compared to international medical facilities. This is true not only of facilities in the
allopathic disciplines, but also to those belonging to the alternative systems of medicine,
particularly Ayurveda. NHP-2001 will assess the-possibilities of encouraging commercial
medical services for patients from overseas:
2.23 IMPACT OF GLOBALIZATION ON THE HEALTH SECTOR
2.23.1 There are some apprehensions about the possible adverse impact of economic globalisation
on the health sector. Pharmaceutical drugs and other health services have always been available
in the country at extremely relatively inexpensive prices, largely due to the effect of the Indian
Patent Act of 1970. India has established a reputation for itself around the globe for innovative
development of original process patents for the manufacture of a wide-range of drugs and
vaccines within the ambit of the existing patent laws. With the adoption of Trade Related
Intellectual Property (TRIPS), and the subsequent alignment of domestic patent laws consistent
with the commitments under TRIPS, there will be a significant shift in the scope of the
parameters regulating the manufacture of new drugs/vaccines. Global experience has shown that
the introduction of a TRIPS-consistent patent regime for drugs in a developing country, would
result in an increase in the cost of drugs and medical services and also obstruct research activities
in developing countries like India. NHP-2001 will address itself to the future imperatives of
health security in the country, in the post-TRIPS era. It shall also engage in a debate to modify the
basic contours of the TRIPS agreement.
2.24 NON - HEALTH DETERMINANTS
2.24.1 Improved health standards are closely dependent on major non-health determinants such as
safe drinking water supply, basic sanitation, adequate nutrition, clean environment and primary
education, especially of the girl child. NHP-2001 will not explicitly address itself to all the
initiatives in these areas, which although crucial, fall outside the domain of the health sector.
However, the attainment of the various targets set in NHP 2001 assumes a reasonable
performance in these allied sectors. The NHP2001 also sets out guidelines in areas where there is
a clear interface between health care and these areas.
2.25 POPULATION GROWTH AND HEALTH STANDARDS
2.25.1 Efforts made over the years for improving health standards have been neutralized by the
rapid growth of the population. Unless the Population stabilization goals-ar-e-achieved, no amount
of effort in the other compone-nts of the public health sector can bring about significantly better
national health standards. Government has separately announced the 'National Population Pokey
2000 \ The principal common features-covered under the National Population Policy 2000 and
NHP 2001, relate to-the prevention and control of communicable diseases; priority to
containment of HIV/AIDS infection; universal immunization of children against all major
preventable diseases; addressing the unmet needs for basic and reproductive health services; and
supplementation of infrastr-ucture. The synchronized implementation of these two Policies
National Population Policy—2000 and National Health Policy 2001—will be the very
cornerstone of any national structural plan to improve the health standards in the country. There is
a growing global consensus on the futility of running separate programmes aimed at population
control; programmes, moreover, that invariably tend to be target oriented and incorporate varying
degrees of coercion. The NHP2001 has noted earlier the need to integrate vertical programmes
within the decentralised primary health care network. The NHP2001 suggests means by which
this can also be done in the case of programmes aimed at population stabilisation. The NHP2001
makes these suggestion while keeping in mind the need to make such a programme entirely free
of targets and coercion, and recognising the principle that families and women within families
have the right to determine the number of children they want.
2.26 ALTERNATIVE SYSTEMS OF MEDICINE
2.26.1 Alternative Systems of Medicine - Ayurveda, Unani, Sidha and Homoeopathy - provide a
significant supplemental contribution to the health care services in the country, particularly in the
underserved, remote and tribal areas. The main components of NHP-2001 apply equally to the
alternative systems of medicine. However, the policy features specific to the alternative systems
of medicine will be presented as a separate document.
3. OBJECTIVES
3.1 The main objective of NHP-2001 is to achieve an acceptable standard of good health amongst
the general population of the country through universal provision of comprehensive primary
health care services. The approach would be to increase access to the decentralized public health
system by establishing new infrastructure in deficient areas, and by upgrading the infrastructure
in the existing institutions. Overriding importance would be given to ensuring a more equitable
access to health services across the social and geographical expanse of the country. Emphasis will
be given to increasing the aggregate public health investment through a substantially increased
contribution by the Central Government. It is expected that this initiative will strengthen the
capacity of the public health administration at the State level to render effective service delivery.
The contribution of the private sector in providing health services would be much enhanced,
particularly for the population group, which can afford to pay for services. Given the situation
today it is envisaged that the private sector will continue to play a role in provision of curative
services, but such a role will need to be monitored through adequate regulatory mechanisms.
Primacy will be given to preventive and first-line curative initiatives at the primary health level
through increased sectoral share of allocation. Emphasis will be laid on rational use of drugs
within the allopathic system. Increased access to tried and tested systems of traditional medicine
will be ensured. Within these broad objectives, NHP-2001 will endeavour to achieve the time
bound goals mentioned in Box-IV.
Box-IV: Goals to be achieved by 2000-2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
2005
Eradicate Polio and Yaws__________________________
”
2005
Eliminate Leprosy
Eliminate Kala Azar
Eliminate Lymphatic Filariasis
2667
Achieve Zero level growth of HIV/AIDS
2010
Reduce Mortality by 50% on account of TB, Malaria and
Other Vector and Water Borne diseases
'201()
Reduce Prevalence of Blindness to 0.5%
Reduce IMR to 30/1000 And MMR to 100/Lakh
” ‘2016'
Improve nutrition and reduce proportion of LBW Babies
from 30% to 10%
2010
Increase utilisation of public health facilities from current
Level of <20 to >75%
2005
Establish an integrated system of surveillance, National
Health Accounts and Health Statistics.
2010
Increase health expenditure by Government as a % of GDP
from the existing 0.9 % to 2.0% 5.0%
2010
Increase share of Central grants to Constitute at least 35%
24% of total health spending
_____
Increase State Sector Health spending from 5.5% to 10% 7% 2005
of the budget.
2010
Further increase to 15% 8%
Im
4. NHP-2001 - POLICY PRESCRIPTIONS
4.1 FINANCIAL RESOURCES
The paucity of public health investment is a stark reality. Given the extremely difficult fiscal
position of the State Governments, the Central Government will have to play a key bigger role in
augmenting public health investments. Taking into account the gap in health care facilities under
NHP-2001 it is planned to increase health sector expenditure in the public sector to 6 5 percent of
GDP, with 2 percent of GDP being contributed as public health investment, by the year 2010. The
State Governments would also need to increase the commitment to the health sector. In the first
phase, by 2005, they would be expected to increase the commitment of their resources to 7 10
percent of the Budget; and, in the second phase, by 2010, to increase it to $ 15 percent of the
Budget. With the stepping up of the public health investment, the Central Government’s
contribution would rise to 2^ 35 percent from the existing 15 percent, by 2010. The^revrsiemftg
of higher public health investments-will also be contingent-upon-the increase in absorptive
capacity of the public health administration so as to gainfully utilize the funds.
4.2 EQUITY
4.2.1 To meet the objective of reducing various types of inequities and imbalances - inter
regional; across the rural - urban divide; and between economic classes - the most cost effective
method would be to increase the sectoral outlay in the primary health sector. Such outlets give
access to a vast number of individuals, and also facilitate preventive and early stage curative
initiative, which are cost effective. In recognition of this public health principle, NHP-2001
envisages an increased allocation of 55 percent of the total public health investment for the
primary health sector; the secondary and tertiary health sectors being targetted for 35 percent and
10 percent respectively. NHP-2001 projects that the increased aggregate outlays for the primary
health sector will be utilized for strengthening existing facilities and opening additional public
health service outlets, consistent with the norms for such facilities. At the same time the increased
quantum of total funds availaible will ensure that secondary and tertiary services are strengthened
too.
4.3 DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
4.3.1 NHP-200-1, envisages a key role for the Central Government in designing national
programmes w-ith the active participation of the State Governments^ Also, the Policy ensures the
provisioning of financial resources, in addition to technical support, monitoring and evaluation at
the national level--by the Centre. However, To optimize the utilization of the public health
infrastructure at the primary level, NHP-2001 envisages the gradual convergence of all health
programmes under a single field administration. All Vertical programmes for control of major
diseases like TB, Malaria and HIV/AIDS would need to be continued till moderate levels of
prevalence are reached would be integrated with the decentralised health care delivery system.
The integration of the programmes will bring about a desirable optimisation of outcomes through
a convergence of all public health inputs. The policy also envisages that programme
implementation be effected through autonomous bodies at State and district levels. State Health
Departments' interventions may bedimited to the overall monitoring of the achievement of
programme targets and other technical aspects. The relative distancing of the programme
implementation from the-S-tate Health Departments will give the project team greater operational
flexibility. Also, the presence of State Government officials,-social-activists, private health
professionals and MLAs/MPs on the management boards of the autonomous bodies will facilitate
well informed decision making. National health programmes will be integrated within the
Primary Health Care system with decentralised planning, decision-making and implementation.
Focus would be shifted from bio-medical and individual based measures to social and community
based measures.
The primary medical care institutions including trained village health workers, sub-centres, and
the PHCs staffed by doctors and the entire range of community health functionaries will be
placed under the direct and administrative control of the relevant level panchayati raj institutions.
The overall infrastructure of the primary health care institutions will be under the control of
panchayati raj and gram sabhas and provision of free and accessible secondary and tertiary care
will be under the control of Zila Parishads, to be accessed primarily through referrals from PHCs.
The essential components of primary care would be:
•
Village level health care based on Village Health Workers selected by the community
and supported by the Gram Sabha/ Panchayat, and the Government health services;
•
Primary Health Centres and subcentres with adequate staff and supplies which provides
quality curative services at the primary health centre level itself with good support from
linkages;
•
A comprehensive structure for Primary Health Care in urban areas based on urban PHCs.
health posts and Community Health Workers;
Enhanced content of Primary Health Care to include all measures which can be provided
at the PHC level even for less common or non-communicable diseases (e.g. epilepsy,
hypertension, arthiritis, pre-eclampsia. skin diseases) abd integrated relevant
epedemiological and preventive measures;
Surveillance centres at block level to monitor the local epedemiological situation and
tertiary care with all speciality services, available in every district.
4.4 THE STATE OF PUBLIC HEALTH INFRASTRUCTURE
4.4.1 As has been highlighted in the earlier part of the Policy, the decentralized Public health
service outlets have become practically dysfunctional over large parts of the country. On account
of resource constraint, the supply of drugs by the State Governments is grossly inadequate. The
patients at the decentralized level have little use for diagnostic ser-viees, which in any case would
still require them to purchase therapeutic drugs privately. In a situation in which the patient is not
getting any therapeutic drugs, there is little incentive for the potential beneficiaries to access the
primary health care system that exists today, seek the advice of the medical prof&ss-iona-l-s-+n the
public health system. This results in there being no demand for medical services. This situation is
further aggravated because medical professionals, and paramedics often absent themselves from
their place of duty. It is also observed that the functioning of the public health service outlets in
the four Southern States - Kerala, Andhra Pradesh, Tamil Nadu and Karnataka - is relatively
better, because some quantum of drugs is distributed through the primary health system network,
and the patients have a stake in approaching the Public health facilities. In this backdrop, NHP2001 envisages the kick-starting of the revival of the Primary Health System by providing some
essential drugs under Central Government funding through the decentralized health system. It is
expected that the provisioning of essential drugs at the public health service centres will create a
demand for other professional services from the local population, which, in turn, will boost the
general revival of activities in these service centres. In sum, this initiative under NHP-2001 is
launched in the belief that the creation of a beneficiary interest in the public health system, will
ensure a more effective supervision of the public health personnel, through community
monitoring, than has been achieved through the regular administrative line of control.
4.4.2 Global experience has shown that the quality of public health services, as reflected in the
attainment of improved public health indices, is closely linked to the quantum and quality of
investment through public funding in the primary health sector. Box-V gives statistics which
show clearly that the standards of health are more a function of accurate targeting of expenditure
on the decentralised primary sector (as observed in China and Sri Lanka), than a function of the
aggregate health expenditure, provided of course the total quantum is above a critical level.
Box-V: Public Health Spending in select Countries
Indicator
%Population
with income of
<$1 day
Infant
Mortality
Rate/1000
%Health
=
Expenditure to
GDP
%Pubhc
Expenditure on
Health to Total
Health
Expenditure
India
44.2
70
5.2
17.3
China
18.5
31
2.7
24.9
Sri Lanka
6.6
16
3
45.4
UK
6
5.8
96.9
USA
7
13.7
44.1
Therefore, NHP-2001, while committing additional aggregate financial resources, places strong
reliance on the strengthening of the primary health structure, with which to attain improved
public health outcomes on an equitable basis. Further-it also recognizes the practical need for
levying reasonable user charges for certain secondary and tertiary public health care services, for
those who can afford to-pay. Global experience has shown that levying of user charges, at any
level, ultimately leads to the denial of services to the poor, who need them most. The NHP2001
calls for enactment of suitable legislations for raising of resources to support public health
investment by taxing people at higher income levels, and also be heavily taxing activities that
have an adverse health impact — like alcohol, tobacco, pan masala, etc.
4.5 EXTENDING PUBLIC HEALTH SERVICES
I.S.l NHP 2001 envisages that, in-the context of the availability and spread of allopathic
graduates in their jurisdict-ion, State-Governments would eonsider-the need for expanding the pool
of medical practitioners to-include-a-cadre of licentiates of medical practicev-as a-lso-practitioners
of Indian Systems of Medicine and Homoeopathy. Simple services/procedures can be provided
by such practitioners even- outside their disciplines-,■ as part of the basic primaF^ealth senwces in
under served areas. Also. NHP 2001 envisages that the scope of-use of paramedical manpower of
allopathic disciplines, in a prescribed functional area adjunct to their cun-ent functions, would
also be examined for meeting simple public health requirements. These extended areas of
functioning of different categories of medical manpower can be permitted, ahenudequate training
and subject to the monitoring of their performance through professi-onal councils.
4.5.2 NHP 2001 also recognizes the need for States to-simplify the recruitment procedures and
rules for-contract employment in order to provide trained medical manpower in under served
U I V LI
.
4.5.1. The NHP2001 envisages that a comprehensive need based humanpower plan for the health
sector will be formulated that addresses the requirement for creation of a much larger pool of
paramedical functionaries and basic doctors in place of the present trend towards over-production
of personnel trained in super-specialities.
4.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS
4.6.1 NHP-2001 lays great emphasis upon the implementation of the decentralised primary health
care programme public health programmes through local self Government institutions. The
structure of the national disease control programmes will have specific components for
implementation through such entities. The Policy urges all State Governments to consider
decentralizing implementation of the programmes to such Institutions by 2005. In order to
achieve this, financial incentives, over and above-the resources allocated for disease control
programmes--will be provided by the Central Government.
4.7 MEDICAL EDUCATION
4.7.1 In order to ameliorate the problems being faced on account of the uneven spread of medical
colleges in various parts of the country, NHP-2001, envisages the setting up of a Medical Grants
Commission for funding new Government Medical Colleges in different under-served parts of the
country. Also, the Medical Grants Commission is envisaged to fund the upgradation of the
existing Government Medical Colleges of the country, so as to ensure an improved standard of
medical education in the country.
4.7.2 To enable fresh graduates to effectively contribute to the providing of primary health
services, NHP-2001 identifies a significant need to modify the existing curriculum. A need based,
skill-oriented syllabus, with a more significant component of practical training, would make fresh
doctors useful immediately after graduation. Major portions of undergraduate medical education
should be imparted in district level medical care institutions, as necessary complement to training
provided in medical colleges. At least an year of rural posting for undergraduate students would
be made mandatory, without which license to practice would not be issued. Similarly, three years
of rural posting after post graduation would be made compulsory.
4.7.3 The policy emphasises the need to expose medical students, through the undergraduate
syllabus, to the emerging concerns for geriatric disorders, as also to the cutting edge disciplines of
contemporary medical research. The policy also envisages that the creation of additional seats for
post-graduate courses should reflect the need for more manpower in the deficient specialities.
4.7.4. No more new colleges would be allowed to be opened in the private sector. Steps would be
initiated to close down medical colleges in the private sector that charge fees above a defined
norm, and those that do not have facilities that shall be laid out as basic necessary standards.
4.8 NEED FOR SPECIALISTS IN PUBLIC HEALTH’ AND ‘FAMILY MEDICINE’
4.8.1 In order to alleviate the acute shortage of medical personnel with specialization in 'public
health’ and ‘family medicine’ disciplines, NHP-2001 envisages a reorientation of the
undergraduate medical curriculum so that these disciplines are adequately emphasised. It also
envisages the progressive implementation of mandatory norms to raise the proportion of
postgraduate seats in these discipline in medical training institutions, to reach a stage wherein 'Ath
of the seats are earmarked for these disciplines. It is envisaged that in the sanctioning of post
graduate seats in future, it shall be insisted upon that a certain reasonable number of seats be
allocated to 'public health’ and 'family medicine’ disciplines. Since, the 'public health’ discipline
has an interface with many other developmental sectors, specialization in Public health may be
encouraged not only for medical doctors but also for non-medical graduates from the allied fields
of public health engineering, microbiology and other natural sciences.
4.9 URBAN HEALTH
4.9.1 NHP-2001, envisages the setting up of an organised urban primary health care structure.
Since the physical features of an urban setting are different from those in the rural areas, the
policy envisages the adoption of appropriate population norms for the urban public health
infrastructure. The structure conceived under NHP-2001 is a two-tiered three-tiered, one: the
primary centre is seen as the first-tier, covering a population of 5,000, with a dispensary
providing OPD facility and essential drugs to enable access to all the national health programmes;
two; a 30 bedded CHC catering to a population of 30,000; and three: a second third-tier of the
urban health organisation at the level of the Government general Hospital, where reference is
made from the primary centre CHC. The Policy envisages that the funding for the urban primary
health system will be jointly borne by the local self-Govemment institutions and State and
Central Governments.
4.9.2 The National Health Policy also envisages the establishment of fully-equipped ‘hub-spoke’
trauma care networks in large urban agglomerations to reduce accident mortality. This would
include training and creation of dispersed facilities to provide adequate "first aid", as well as
equipped secondary and tertiary care centres.
4.10 MENTAL HEALTH
4.10.1 NHP - 2001 envisages a network of decentralised mental health services for ameliorating
the more common categories of disorders. The programme outline for such a disease would
envisage diagnosis of common disorders by general duty medical staff and prescription of
common therapeutic drugs. The NHP2001 envisages promotion of measures towards mental
health that promote a shift away from a bio-medical model towards a holistic model of mental
health. Community support and community based management of mental health problems would
be promoted. Services for early detection and integrated management of mental health problems
would be integrated with Primary Health Care.
4.10.2 In regard to mental health institutions for in-door treatment of patients, the policy
envisages the upgrading of the physical infrastructure of such institutions at Central Government
expense so as to secure the human rights of this vulnerable segment of society. The policy shall
draw up guidelines for minimum standards that need to be adhered to in mental health
institutions, and also enact suitable laws to ensure strict adherence to these.
4.11 INFORMATION, EDUCATION AND COMMUNICATION
4.11.1 NHP-2001 envisages an IEC policy, which maximizes the dissemination of information to
those population groups, which cannot be effectively approached through the mass media only.
The focus would therefore, be on inter-personal communication of information and reliance on
folk and other traditional media. The IEC programme would set specific targets for the
association of PRIs/NGOs/Trusts in such activities. The programme will also have the component
of an annual evaluation of the performance of the non-Govemmental agencies to monitor the
impact of the programmes on the targeted groups. The Central/State Government initiative will
also focus on the development of modules for information dissemination in such population
groups who normally, do not benefit from the more common media forms.
4.11.2. NHP-2001 envisages priority to school health programmes aiming at preventive health
education, regular health check-ups and promotion of health seeking behaviour among children.
The school health programmes can gainfully adopt specially designed modules in order to
disseminate information relating to ‘health’ and ‘family life’. This is expected to be the most costeffective intervention as it improves the level of awareness, not only of the extended family, but
the future generation as well.
4.12 MEDICAL HEALTH RESEARCH
4.12.1 NHP-2001 envisages the increase in Government-funded medical research to a level of 4
2.5 percent of total health spending by 2005; and thereafter, up to 2 5 percent by 2010. Domestic
medical research^vould be focused on new therapeutic drugs-and-vaccines for tropical diseases,
such as TB and Malaria, as also the Sub-types of HIV/AIDS prevalent in the country. Research
programmes taken up by the Government in these priority ar-eas-weu-ld be conducted in a mission
mode. Emphasis would also be paid to time-bound applied-research for developing operational
applications. This would ensure cost effective dissemination of existing / future therapeutic
drugs/vaccines in the general population. Private entrepreneurship-w-ill be encouraged in the field
of medical research for new molecules / vaccines.- NHP 2001 envisages focusing of Health
Research in the country, first, on optimisation of public health strategies, and also on therapeutic
drugs/vaccines development for tropical diseases, which are normally neglected by international
pharmaceutical companies on account of limited profitability potential. Research activities will
also need to focus on the newly-emerging frontier areas of research based on genetics, genome
based drug and vaccine development, molecular biology, etc.
4.13 ROLE OF THE PRIVATE SECTOR
4.13.1 NHP2001 will initiate measures to ensure that the unbridled and unchecked growth of the
commercial private sector is brought to a halt. Strict observance of standard guidelines for
medical and surgical intervention and use of diagnostics, standard fee structure, and periodic
prescription audit shall be made obligatory. Legal and social mechanisms will be set up to ensure
observance of minimum standards by all private hospitals, nursing/matemity homes and medical
laboratories. The prevalent practice of offering commissions for referral will be made punishable
by law. For this purpose a body with statutory powers will be constituted, which has due
representation from peoples organisations and professional organisations. N-H-P-2001 e-nvisages
the enactment of suitable-legislations for regulating minimum infrastructure and quality standards
by 2003, in climeal establishments/medical institutions; also-, statutory guidelines for the conduct
of clinical practice and delivery of medical services are to be developed over the same period.
The policy also encourages the setting up of private-insurance instruments-fer increasing the
scope of the coverage of the secondary and tertiary seetor -under private health insurance
packages
4.13.2 To capitalize on-the-comparative cost-advantage enjoyed by domestic-health facilities in
the secondary and tertiary sector, the policy will-encourage the supply of services to patients of
foreign origin on payment. The rendering-of such services-on-pa-yment in foreign exchange-will
be treated as deemed exports’ and will be made eligible for all fiscal incentives extended to
export earnings.
4.13.3 NHP-2001 envisages the co-option of the non-governmental practitioners m-the-naEenal
disease control programmes-se-as to ensure that standard treatment protocols are followed in their
day-to-day practice.
4.13./1 NHP 2001 recognizes the immense potential of use of information technology applications
in the area of tele medicine in the tertiary health care sector. The use of this technical aid will
greatly enhance the capacity-for the professionals to pool their clinical experience.
4.14 ROLE OF THE CIVIL SOCIETY
4.14.1 NHP-2001 recognizes the significant contribution made by NGOs and other institutions of
the civil society in monitoring public health programmes and in ensuring community mobilisation
and participation as regards public health programmes, making available-health services to the
community. NHP2001 envisages the utilisation of NGOs and civil society organisations in the
monitoring of public health programmes and in increasing participation of local communities in
planning and implementation of such programmes. They would also have a major role in
community mobilisation, and in building the capacities of Panchayati Raj Institutions. In order to
utilize on an increasing scale, thek-high motivational skills, NHP 2001 envisages that the disease
control programmes should earmark a definite portion of the budge^-in respect of identified
programme components, to be exclusively implemented through these institutions.
4.15 NATIONAL DISEASE SURVEILLANCE NETWORK
4.15.1 NHP-2001 envisages the full operationalization of an integrated disease control network
from the lowest rung of public health administration to the Central Government, by 2005. The
programme for setting up this network will include components relating to installation of data
base handling hardware; IT inter-connectivity between different tiers of the network; and, in
house training for data collection and interpretation for undertaking timely and effective response.
4.16 HEALTH STATISTICS
4.16.1 NHP-2001 envisages the completion of baseline estimates for the incidence of the
common diseases - TB, Malaria, Blindness - by 2005. The Policy proposes that statistical
methods be put in place to enable the periodic updating of these baseline estimates through
representative sampling, under an appropriate statistical methodology. The policy also recognizes
the need to establish in a longer time frame, baseline estimates for : the non-communicable
diseases, like CVD, Cancer, Diabetes; accidental injuries; and other communicable diseases, like
Hepatitis and JE. NHP-2001 envisages that, with access to such reliable data on the incidence of
various diseases, the public health system would move closer to the objective of evidence-based
policy making.
4.16.2 In an attempt at consolidating the data base and graduating from a mere estimation of
annual health expenditure, NHP-2001 emphasis on the needs to establish national health
accounts, conforming to the 'source-to-users’ matrix structure. Improved and comprehensive
information through national health accounts and accounting systems would pave the way for
decision makers to focus on relative priorities, keeping in view the limited financial resources in
the health sector.
4.17 WOMEN’S HEALTH
4.17.1 NHP-2001 envisages the identification of specific programmes targeted at women’s health.
The policy notes that women, along with other under privileged groups are significantly
handicapped due to a disproportionately low access to health care. The various Policy
recommendations of NHP-2001, in regard to the expansion of primary health sector
infrastructure, will facilitate the increased access of women to basic health care. NHP-2001
commits the highest priority of the Central Government to the funding of the identified
programmes relating to woman’s health. Also, the policy recognizes the need to review the
staffing norms of the public health administration to more comprehensively meet the specific
requirements of women.
4.17.2. NHP2001 will set in operation Women-centered health initiatives that include:
• awareness generation for social change on issues of gender and health, triple work
burden, gender discrimination in nutrition and health-care;
• preventive and curative measures to deal with health consequences of womens' work
and domestic violence;
• complete maternity benefits and child care facilities to be provided in all occupations
employing women, be they in the organized or unorganized sector;
• special support structures that focus on single, deserted, widowed women and
commercial sex workers; gender sensitive services to deal with reproductive health
including reproductive system illnesses, maternal health, abortion, and infertility;
• vigorous public campaign accompanied by legal and administrative action against
female feticide, infanticide and sex pre-selection.
POPULATION POLICY
All coercive measures including incentives and disincentives for limiting family size would be
abolished. The right of families and women within families in determining the number of children
they want should be recognised. Concurrently, access to safe and affordable contraceptive
measures would be ensured which provides people, especially women, the ability to make an
informed choice. All long-term, invasive, systemic hazardous contraceptive technologies such as
the injectables (NET-EN. Depo-Provera, etc.), sub-dermal implants (Norplant) and anti fertility
vaccines would be banned from both the public and private sector. Urgent measure would be
initiated to shift to onus of contraception away from women and ensure at least equal emphasis on
men's responsibility for contraception.
CHILD HEALTH
The NHP2001 shall put in operation Child centered health initiatives which include:
• a comprehensive child rights code, adequate budgetary allocation for universalisation of
child care services, a expanded and revitalized ICDS programme and ensuring adequate
support to working women to facilitate child care, especially breast feeding;
• a cmprehensive supplementary feeding programme and nutrition awareness programme
that addresses the needs of all umdemourished children below the age of 5;
• comprehensive measures to prevent child abuse and sexual abuse;
• educational, economic and legal measures to eradicate child labour, accompanied by
measures to ensure free and compulsory primary education for all children.
4.18 MEDICAL ETHICS
4.18.1 NHP - 2001 envisages that, in order to ensurethat the common patient is not subjected to
irrational or profit-driven medical regimens, a contemporary code of ethics be notified and
rigorously implemented by the Medical Council of India.
4.18.2 NHP—2001 does not offer any policy-prescription at this-stage relating to ethics in the
conduct of medical research. By and large medical research within the country is limited in these
frontier disciplines of gene manipulation and stem cell research. However, the policy recognises
that a vigilant watch will have to be kept so that appropriate guidelines and statutory provisions
are put in place when-medical research in the country reaches the stage to make such issues
relevant.
4.18.2. Ethical guidelines for research involving human subjects shall be drawn up and
implemented after an open public debate. No further experimentation, involving human subjects.
will be allowed without a proper and legally tenable informed consent and appropriate legal
protection. Failure to do so to be punishable by law. All unetical research, especially in the area
of contraceptive reseach, would be stopped forthwith. Women (and men) who, without thenconsent and knowledge, have been subjected to experimentation, especially with hazardous
contraceptive technologies will be traced forthwith and appropriately compensated. Exemplary
damages shall be awarded against the institutions (public and private sector) involved in such
anti-people, unethical and illegal practices in the past.
ENSURING ACCESS TO ESSENTIAL DRUGS, AND RATIONAL DRUG USE
The NHP2001 envisages the formulation of a rational drug policy, under the aegis of the Ministry
of.Health, that ensures development and growth of a self reliant industry for production of all
essential drugs at affordable prices and of proper quality. The policy should, on a priority basis:
• ban all irrational and hazardous drugs;
• introduce production quotas and price ceiling for essential drugs;
• promote compulsory use of generic names;
• regulate advertisements, promotion and marketing of all medications based on ethical
criteria:
• formulate guidelines for use of old and new vaccines;
• control the activities of the multinational sector and restrict their presence only to areas
where they are willing to bring in new technology;
• recommend repeal of the new patent act and bring back mechanisms that prevent creation
of monopolies and promote introduction of new drugs at affordable prices;
• promotion of the public sector in production of drugs and medical supplies, moving
towards complete self-reliance in these areas.
4.19 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DRUGS
4.19.1 NHP - 2001 envisages that the food and drug administration will be progressively
strengthened, both in terms of laboratory facilities and technical expertise. Also, the policy
envisages that the standards of food items will be progressively tightened at a pace which will
permit domestic food handling / manufacturing facilities to undertake the necessary upgradation
of technology so as not to be shut out of this production sector. The policy envisages that,
ultimately food standards will be close, if not equivalent, to codex specifications-; and drug
standards will be at par with the mest-r-igOFeu-s-ones adopted elsewhere.
4.20 REGULATION OF STANDARDS IN PARAMEDICAL DISCIPLINES
4.20.1 NHP-2001 recognises the need for the establishment of statutory professional councils for
paramedical disciplines to register practitioners, maintain standards of training, as well as to
monitor their performance.
4.21 OCCUPATIONAL HEALTH
4.21.1 NHP-2001 envisages the periodic screening of the health conditions of the workers,
particularly for high risk health disorders associated with their occupation.
421.2. NHP2001, further, envisages special measures relating to occupational and environmental
health which will focus on:
• banning of hazardous technologies in industry and agriculture:
• worker centered monitoring of working conditions with the onus of ensuring a safe
workplace on the management;
• reorientation of medical services for early detection of occupational disease:
• special measures to reduce the likelihood of accidents and injuries in different settings,
such as traffic accidents, industrial accidents, agricultural injuries, etc.
4.22 PROVIDING MEDICAL FACILITIES TO USERS FROM OVERSEAS
4.22.1 NHP 2001 strongly encourages the providing of health services on a commercial basis to
service seekers from overseas. The providers of such services to patients Trom overseas will be
encouraged-by extending to their eamings-in foreign-exchange, all fiscal incentives-available to
ether exporters of goods and services.
4.23 IMPACT OF GLOBALISATION ON THE HEALTH SECTOR
4.23.1 NHP-2001 takes into account the serious apprehension expressed by several health
experts, of the possible threat to the health security, in the post TRIPS era, as a result of a sharp
increase in the prices of drugs and vaccines and constraints on medical research. To protect the
citizens of the country from such a threat, NHP-2001 envisages a national patent regime for the
future which, while being consistent with TRIPS, avails of all opportunities to secure for the
country, under its patent laws, affordable access to the latest medical and other therapeutic
discoveries. The Policy also sets out that the Government will bring to bear its full influence in all
international fora - UN, WHO, WTO, etc. - to secure commitments on the part of the Nations of
the Globe, to lighten the restrictive features of TRIPS in its application to the health care sector.
RESTRICTION ON HAZARDOUS PRACTICES /INDUSTRIES
NNP2001 envisages effective restriction on industries that promote addictions and an unhealthy
lifestyle, like tobacco, alcohol, pan masala etc., starting with an immediate ban on advertising and
sale of their products to the young, and provision of services for de-addiction.
PROMOTION OF HEALTH AMONG PHYSICALLY & MENTALLY CHALLENGED
NHP2001 envisages measures to promote the health of physically and mentally disadvantaged by
focussing on the abilities rather than deficiencies. Focus would be on promotion of measures to
integrate them in the community with special support rather than segregating them; ensuring
equitable opportunities for education, employment and special health care including rehabilitative
measures.
5. SUMMATION
5.1 The crafting of a National Health Policy is-a rare occasion in public affairs when it would be
legitimate, inde-ed-valuable, to allow-our dreams to mingle with-our underst-and-ing of ground
realities. Based purely on the clinical facts defining the current status of the health sector, we
would have arrived at a certain policy formulation; but, buoyed-by-our dreamsrwe have ventured
slightly beyond that in the shape of NHP 2001 which, in fact, defines a vision for the future.
5.2 The health needs of the country are enormous and the financial resources and managerial
capacity available to meet it, even on the most optimistic projections, fall somewhat short. In this
situation, NHP-2001 has had to make hard choices between various priorities and operational
options. NHP-2001 does not claim to be a road-map for meeting all the health needs of the
populace of the country. Further, it has to be recognized that such health needs are also dynamic
as threats in the area of public health keep changing over time. The Policy, while being holistic,
undertakes the necessary risk of recommending differing emphasis on different policy
components. Broadly speaking, NHP - 2001 focuses on the need for enhanced funding and an
organizational restructuring of the national public health initiatives in order to facilitate more
equitable access to the health facilities. Also, the policy is focused on those diseases which are
principally contributing to the disease burden - TB, Malaria and Blindness from the category of
historical diseases; and HIV/AIDS from the category of ‘newly emerging diseases’. This is not to
say that other items contributing to the disease burden of the country will be ignored; but only
that, resources as also the principal focus of the public health administration, will recognize
certain relative priorities.
5.3 One nagging imperative, which has influenced every aspect of NHP-2001, is the need to
ensure that ‘equity’ in the health sector stands as an independent goal. In any future evaluation of
its success or failure, NHP-2001 would like to be measured against this equity norm, rather than
any other aggregated financial norm for the health sector. Consistent with the primacy given to
‘equity’, a marked emphasis has been provided in the policy for expanding and improving the
primary health facilities, including the new concept of provisioning of essential drugs through
Central funding. The Policy also commits the Central Government to increased under-writing of
the resources for meeting the minimum health needs of the citizenry. Thus, the Policy attempts to
provide guidance for prioritizing expenditure, thereby, facilitating rational resource allocation.
5.4 NHP-2001 highlights the expected roles of different participating group in the health sector.
Further, it recognizes the fact that, despite all that may be guaranteed by the Central Government
for assisting public health programmes, public health services would actually need to be delivered
by the State administration, NGOs and other institutions of civil society. The attainment of
improved health indices would be significantly dependent on population stabilisation, as also-en
complementary efforts from other areas of the social sectors - like improved drinking water
supply, basic sanitation, minimum nutrition, etc. - to ensure that the exposure of the populace to
health risks is minimized.
Draft NHP, 2001 - a Brief Critique
The National Health Policy draft has finally been released by the Ministry of Health and Family
Welfare, early this month. The draft is available on the website of the ministry, which says that
comments on the draft will be entertained for a month. We would first like to register our protest
regarding the arbitrary manner in which this policy is sought to be finalised. The last Health
Policy document by the government was released in 1983. We appreciate that in this intervening
period developments in the socio-economic and political spheres, both within and outside this
country, would necessitate the formulation of a new policy. But one would have assumed that
such a process would involve wide ranging discussions at all levels. Moreover, as the draft itself
repeatedly states, Health is a State subject as per our Constitution. Yet we have a document
foisted upon us that has been put together by bureaucrats sitting in Nirman Bhawan. From all
accounts the State governments have not been involved in the process of drafting, nor has the
Central Council of Health and Family Welfare been consulted (which is the apex body that has
representatives from all State Health Departments). And now, just one month is being provided to
give comments on a policy that is being drafted after 18 years! Moreover, a policy that one
gathers has been at the drafting stage for three years!
Compromise and Contradictions
The draft appears to be a compromise effort that marries contradictory concerns. Section 2,
titled,” Present Scenario" analyses many of the present initiatives and their deficiencies. Some of
the conclusions drawn in this section are premised on correct assumptions. However, many of
these assumptions are ignored or contradicted in the operative part of the draft. Section 4, titled
"policy prescriptions". It appears as though the two have been drafted by two different sets of
individuals. While the draft makes appropriate references about decentralisation, inadequate
funds, non-viability of vertical programmes, inadequate and dysfunctional infrastructure, etc. in
Section 2, there are either no matching policy prescriptions in section 4 or these prescriptions are
expressed in vague generalities. Practically the only areas where the draft makes specific
recommendations, are areas that relate to encouragement of the private sector and legitimisation
of privatisation of the health care delivery system.
Fund Allocation — Too Little Too Late
A further perusal of the draft throws up many fundamental concerns. Possibly the draft is most
eloquent where it is silent about certain areas. We shall return to these later, after discussing what
the draft does say. The draft admits that public health investment has been “comparatively low”.
What it does not admit is that it has, in fact, been abysmally low - one of the lowest in the world.
What it also does not admit is the fact that such investment as a percentage of total health
expenditure is possibly the lowest in the world - in other words that India has the most
privatised health system in the world! The draft recommends an increase in public health
expenditure from the present 0.9% of GDP to 2.0% in 2010. While any mention of an intention to
increase public expenditure is welcome, the quantum suggested is too little and comes too late. It
falls far short of the 5% of GDP that has been a long-standing demand of the health movement.
Moreover the draft projects that public expenditure in 2010 will be 33% of total health
expenditure - up from the present 17%. But even 33% is lower than that of the average of any
region in the globe today - in other words we visualize that India would continue to be one of the
most privatised health system in the world even in 2010! The draft is eloquent on the inability of
states to increase expenditure on health care and laments that the allocation by states has in fact
decreased in the past decade. There is a veiled attempt to castigate the states for their inability to
increase expenditure. Such insinuations are uncalled for without a detailed analysis of the manner
in which the liberalisation process has shattered the financial stability of states. It is all the more
objectionable given the fact that the formulation of the draft has seen no participation from the
states, where they would have been in a position to record their point of view.
Top-Down Prescriptions
The draft, for all the rhetoric on community participation, is replete with "top down"
prescriptions. While admitting the wastage involved in running Centrally sponsored and
controlled vertical disease control programmes and envisaging their integration in the
decentralised primary health care system, it goes on to recommend that we would need to retain
many of them! All subsequent formulations in the draft, especially in the section on policy
formulations, assumes the continuance of vertical programmes. Moreover the draft repeatedly
asserts that the Centre will continue to plan all public health programmes. The draft continuously
harps on the availability of expertise with the Centre, to justify strong Central control. It is not
clear where the basis of such assertions lie. On the other hand the draft is delightfully vague about
actual devolution of responsibility and financial powers to PRIs and relocation of accountability
to appropriate levels of local self-governments. In the absence of such clarity there is the danger
of the primary health care system becoming a Collector driven exercise, that is controlled by the
Centre - thereby defeating the entire effort at decentralisation.
Prescriptions for Privatisation
Numerous formulations in the draft, in various forms, clear the way for even greater privatisation
of the health care system. In the garb of encouraging “civil society” organisations the draft talks
about a greater role being provided to NGOs. The draft says, “the NHP will
suggest policy
instruments for implementation of public health programmes through individuals and institutions
of civil society”. In our view this constitutes a veiled attempt to clear the way for sub contracting
public health to NGOs.
The draft introduces the concept of user fees, albeit couched in the usual sugar coating of it being
introduced for those who can pay. Global experience of user fees at any level shows that they
serve only one purpose - to drive out the poor and the indigent. Any mention of user fees in a
health policy draft is objectionable and untenable. The section that suggests targeting of primary
health care for resource allocation needs to be read along with this prescription for introduction of
user fees. While targeting of primary health care is to be welcomed, this should not constitute an
argument for the legitimisation of the government’s retreat from providing comprehensive and
quality secondary and tertiary care. The draft hints at this possibility in different sections and also
hints at “encouraging” the private sector to occupy the space that would be left vacant.
The draft talks about using Indian health facilities to attract patients from other countries. It also
suggests that such incomes can be termed “deemed export” and should be exempt from taxes.
This formulation draws from recommendations that the industry has been making and specifically
from the “Policy Framework for Reforms in Health Care”, drafted by the prime Minister’s
Advisory Council on Trade and Industry, headed by Mukesh Ambani and Kumaramangalam
Birla. Such a proposal, termed by many as “health tourism”, will divert our best resources to
serve the interests of the global health market and create islands of brain and resource drain
within the country. It is a proposal that needs to be rejected outright. The draft also, presumably
drawing inspiration from the same report, talks of encouraging "the setting up of private
insurance instruments for increasing the scope of the coverage of the secondary and tertiary sector
under private health insurance packages". Further, there are repeated references in the draft about
"valuable" contributions made by the private sector and the need to "encourage" more such
contributions. While the draft is repeatedly critical of the public health system (justifiably so)
there is not a single word of criticism of the ills of the private medical care system, though
reference is made to the need to develop regulatory norms.
Important Concerns Ignored
Other important concerns are either ignored or referred to only in passing. The draft has a fourline section on women’s health, without any specific proposals being spelt out. Child health is not
even afforded a separate section, and is dealt with through passing references. It is silent on child
nutrition in spite of the shameful fact that a half of children below 5 are malnourished in India — a
dubious distinction that India shares with only one other country (Bangladesh) in the world.
In the area of medical education the draft talks of the need to introduce postgraduate courses in
“family medicine”. The long-standing position of the health movement has been to limit
specialisation and reorient undergraduate education to equip doctors in a manner that they are
able to better address health needs of the common people. Such a purpose cannot be served by
just introducing another specialty called family medicine. The draft betrays a total lack of
understanding regarding the need to create a medical education system oriented to the needs of
primary care, and instead is steeped in the bias of urban specialist-based health care. On the other
hand it is entirely silent about the bane of private medical colleges and the need to restrict and
regulate these institutions.
The section on Research harps on "frontier areas" and medical research. There is no
understanding of the necessity to initiate and sustain research on public health. There is no
mention of the necessity to regulate medical research and to develop ethical criteria in this regard.
The impact of TRIPS is discussed in terms of possible impact on drug prices, but there is no
mention of the crippling effect of TRIPS on medical research.
Eloquent Silence
As mentioned earlier the draft is most eloquent where it is silent. The draft, very consciously,
abjures the words comprehensive and universal health care. In contrast the NHP 1983 had
said: "India is committed to attaining the goal of "Health for All by the Year 2000 A.D." through
the universal provision of comprehensive primary health care services". The new draft, thus,
repudiates a fundamental concept of the NHP 1983 and the Alma Ata declaration. It is also
conspicuously silent on the village health worker - the first contact in the primary health care
system. In other words, by its silence, the draft provides a framework for the dismantling of the
whole concept of primary health care. Significantly, the section on policy prescriptions in the
draft is entirely silent on the content of the primary health care system.
The draft has nothing substantive to say of the population control programme, which the health
movement has long held to constitute a major drain on primary health care. It repeats the usual
sophistry that advances in public health have been nullified by increase in population. This refrain
contradicts all evidence available across the globe, which show that population stabilisation
follows attainment of certain socio-economic standards and do not precede them.
The draft is practically silent about pharmaceuticals and their impact on health care - thereby
accepting that it has no role in formulation of the drug policy. This is even more surprising given
the fact that a new Drug Policy is being discussed by the Industry Ministry today, and reports
about the policy have been available for some months. The new policy, it is believed, will
recommend further relaxation of price and production controls. Are we to understand that the
NHP believes that increased drug prices and non-availability of essential drugs have no impact on
the health sector?
In brief, the draft constitutes a return from Alma Ata, a return to the concept of centrally directed
institution based health care, much of the pious rhetoric notwithstanding. If allowed to be
enshrined in its present form, the NHP can be used as a tool to legitimise privatisation f the health
sector.
file:///Un-
Subject:
Date:
brom:
To:
Dear ail,
[pha-ncc] NHP-critique
Thu, 27 Sep 2001 19:49:37 +0530
‘cehat" <cehaWvsnl.com>
<pha-ncc@yahoogroups.com>
This is in response to Aniit’s meticulously prepared drafts about the NIIP.
I am attaching herewith two files. The first file contains Amit’s draft of our short critique of NHP. I have
suggested a number of minor changes in this draft. These suggestions have been marked with the help of’ Track
Changes’ in the ’Tools’ menu option.
In the second file I have suggested some corresponding changes in the alternative version prepared by Amit.
Tn general, I have tried to tighten the draft by deleting repetitions etc, and have deleted some sharp expressions.
If we want to have a ’dialogue’ with the policy makers, I don’t think we should be lashing out, unless it is very
necessary. I have brought forward the section ’Eloquent Silence’ because it starts with reference to HFA and
Alma Ata declaration and I feel it’s a good start to make.
t he only two important changes I would like to suggest are as follows-
i) I would argue that let us suggest that catering to foreign patients to earn dollars should be not more than say
10% of the total number of indoor patients But we cannot be against this activity as such. Otherwise, we will
have io be against export of drugs or any oihei pi oduct,” unless all the needs of the Indian people are met”.
2)There should be explicit stand on limiting cross -practice. We have been ar guing that
non-aiiopathic degree holders working in rural areas be allowed to use a limited list of drugs for Primary Health
Care after giving them some systematic retraining for a few months. But there should be strict legal action if
they exceed their limits.
This point is important as there are about 8 Lac non-allopathic degree holders compared to about 4 Lac
allopaths. Almost all these non-allopaths use allopathic drugs without any restrictions whatsoever, with nobody
taking any action against them.
It was decided in the Mumbai meeting that the table, which compares our People’s Health Charter with the
NHP, should be given to the Health Minister, as one of the annexui es. The Pune office of CEHAT is sending
the electronic copy of this table to you.
Wann Regards.
Anant Phadke
critique of NIIT, Anant-commcnts.doc
Name:
type:
critique of NHP, xAnant-comments.doc
winword file (appiication/msword)
Hcalih~l.itf
Name:
Health-1.rtf
1 of 2
D
/vu
9/28/01 11:1
Draft NHP, 2001 - a Brief Critique
The National Health Policy Draft has finally been released by the Ministry
of Health and Family Welfaie, eaily this month. The Draft is available on
the website of the ministry, which says that comments on the Draft will be
entertained for a month. We would first like to register our protest
regarding the arbitrary manner in which this policy is sought to be
finalised. The last Health Policy document by the government was released in
1983. We appreciate mat in this intervening period developments in the
socio-economic and political spheres, both within and outside this country,
would necessitate the formulation of a new policy. But one would have
^sisnmed that such a process would involve wide ranging discussions at all
levels. Moreover, as the Draft itself repeatedly states, Health is a State
subject as per our Constitution Yet ■we-have-a-doewnent foisted upomts that
Ims beon^put together by bureaucrais sitting in Nirmaa-Bhawan. From all
accounts the Stale governments have not been involved in the process of
drafting, nor has the Central Council of Health and Family "Welfare been
consulted (which is the apex body that has representatives from ail State
Health Departments). And now, just one month is being provided to give
comments on a policy tiiai is being drafted after 18 years! Moreover, a
policy that one-gathers reportedly has been at the drafting stage for three years!
Eloquent Silence
n
H
The Draft is most eioquenl where it is silent. It completely omits the very concept of
comprehensive and universal health care. Tn contrast the NHP 1983 had said: "India is committed
to attaining the goal of "Healtli for All by the Year 2000 A.D." through the
□
universal_proyision_of Aoy_primaryJivalth cju'e.seivjcesA The
Draft, thus, departs from the fundamental concept of the NHP_ 1983 and t
Ata declaration. It is also conspicuously silent on the village health
worker - the first contact in me primary health care .system. By its silence, the Draft provides.a
framework for the dismantling of th? whole concept of primary health care. Significantly, the
section on puiicy prescriptions in die Draft is entirely silent on the cun tun I of the
primary health care system
The Draft has nothing substantive to say of the population control
programme, which the health movement has long held to constitute a major
I
I
I
I
I
I
I
I
drain on primary health care. It repeats the usual sophistry that advances
in public health have been .nullified by incre.asein pppirtmion./rhLs refram
contradicts all evidence available across the globe, which show that
pupuialion stabilisation follows auainmeiil of certain sociu-uuunumic
standards and do not precede them.
The Draft is practically silent about pharmaceuticals and their impact on
health cai e tliei eb j aocepiiiig that it lias no role in formulation of the
drugppiicy. This is_eyen morejmi^
Policy is being discussed by the Industry Ministry today, and reports about
the policy have oeen avaiiabie for some months. The new policy, has reportedly recommended
further relayation of price and production controls. Are we to understand thr*t the NHP believes that
hici eased drug pi ices and iion-avainibiiity of essential drugs have no impact on the health
sector?
Important Concerns Ignored
□
n
Other iinpoi taut uuncei ns ai e either ignored or referred to only in passing.
n
The Draft has a four-line section on womer/s health, without any specific
□
proposals being spelt out. Child health is not even afforded a separate
section, and is dealt with through passing references. It is silenLorLchjld
n_uUitLou_in_spite pXthe_shaniefu! jacHhat a half of children bel_Q5y_5_arg
malnourished in India — a dubious distinction that India shares with only
one other country (Bangladesh) in the world.
I
I
In the area of medical education the Draft talks of the need to introduce
postgradujUe.cpjirs^JaJTaaijlyjnedivin^
health movement has been to limit specialisation and reorient utidergradu^g
education to equip doctors in a manner that they are able to better address
neailh needs pi the common people. Such a purpose cannot be served by j ust
introducing another specialty called family medicine. The Draft, betrays a
io tai iavk of understanding rcgai ding the need to create a medical education
system oriented to the need^ of primary care, and instead is steened in the
bias of urbari spvciaiist-basvd livalui carv. On llic other hand it is entirely
silent about the bane of private medical colleges and the need to stop the setting up of new private
medical collegesaad regulate these institutions.
i
i
I
i
I
!
I
I
I
I
I
I
The section on Research harps on "frontier _areas"_and medical research.
There is no understanding of the necessity to initiate and sustain research
on public health. There is no mvmion of tliv necessity io regulate medical
research and to develop ethical criteria in this regard. The impact of TRIPS
is discussed in terms of possible impact on drug prices, but there is no
mention of the crippling effect of TRIPS on medical research.
Compromise and Contradictions
.M
w
The Draft appears to be a compromise effort that marries contradictory
concerns. Section 2, titled,” Present Scenai io” analyses many of the present
initiatives and their deficiencies. Some of the conclusions drawn in this
section are premised on correct assumptions. However, many of these
assumptions are mnored or contradicted in the operative part of the Draft,
Section 4, titled "policy prescriptions”. Itappears^s-^eughThe-tv/o-ha^
been Drafted by two diiierent sets-er^idividuais.WhUe t The Draft makes
appropriate references about decentralisation, inadequate funds,
nun-viability of vertical programmes, inadequate and dysfunctional
infrastructure, etc in Section 2,However, there are either no matching policy
prcscriptiuHS in section 4 or these prcsci iptions arc expressed in vague
generalities.Out ot the mam policy prescriptions, most Practically the only areas where the Draft
makes specific
recommendafttms;-are-areas-mat relate to encouragement of the private
sector and legitimisaiion of privatisation of the health care deliveiy system
Increased Fund Allocation -- Ton Tittle Ton Late and overdue
'if
A further perusal of the Draft throws up many fundamental concerns. Possibly
tlieTJraft k-most eloquent •wfcer0-it-i&-silent about^eilamareas. We shall
retur-nto-these-^er^afteFfttscussm^^ftat-the-Draft-dees-sayT 1 he Draft
admits that public health investment has been ’’comparatively low”. What it
does not admit is that it has. in fact, been abysmally low - one oiW
lowest in the world; What it also docs not admit is the fact that such
investment as a pci ventage of total health expenditure is possibly the
lowest in the world m-other-werd^ that India has the most privatised
health system in the world' The Draft recommends aa-welcome increase in public
health expenditure from the present 0.9% of GDP to 2.0% in 2010. While any
mention of an intention to increase public expenditure is welcome, the However
quantum suggested is too little and comes tee- ver; late. It falls far short of
the 5% of GDP that has been a iong-sianding demand of the health movement and recommended
by WHO long back.
Moreover die Draft projects tiiat public expenditure in 2010 wiii be 33% of
total health expenditure - un from the present 17%. But even 33% is lower
ihaii that of the average of any region in the globe today — in other wor^s
we-vhaial-^e-that India would continue to be one of the most privatised
health system in the world even in 2010* The Draft is eloquent on the
inability of states to increase expenditure on health care and laments that
the allocation by states has in fact decreased in the past decade. There is
a veiled auempi io castigate the states for their inability to increase
expenditure, ^uch insinuations are uncalled for without a detailed analysis
of the manner in which the liberalisation process has shattered the
financial stability of states. It all the more objectionable given the
fact that tfe formulation of the-DrafTlias-s^otwio^4icip<^wa^om the
states
they- would- havo been-Hi ar position-to- reoor-d their -po mt ot-view.
Top-Down Prescriptions
Hie Draft, for all the rhetoric on community pai ticipalion, is replete with
’’top down” prescriptions. While admitting the wastage involved in running
Centrally sponsored and controlled vertical disease control programmes and
envisaging their integration in the decentralised primary health care
system, it goes on to recommend that we would need to retain many of them *
All subsequent formulations in me Draft especially in the section on
policy formulations, assumes the continuance of vertical programmes.
Moreover the Draft repeatedly asserts that the Centre wiii continue to plan
all public health programmes The ririft continuously harps on the
availability of expci tise with the Centre, io justify strong Central
control. It is not clear where the basis of such assertions lie. On the
other hand the Draft is delightfully vague about actual devolution of
responsibility and financial powers to FanchayatRaj Institutions _( PRls) and relocation of
accountability7
to appropriate levels or local self-governments. In the absence of such
clarity there is the danger of the primary health care system becoming a
Collector driven exercise, dial is conii oiled by the Centre - thereby
defeating the entire effort at decentralisation.
Prescriptions for Further Privatisation
Numerous formulations in the Draft, in various forms, clear the way for even
greater privatisation of the health care system. fft-tite-gafb-efenemiFagmg
’’civil sooie^” organisati-ons the Draft-talks about a grejiter role being
provided lo NGGs. The Draft says, ’’the NHP will—85.. suggest policy
instruments for implementation of public health programmes through
individuals and institutions of civil society”. In our view-fThis constitutes
a veiled attempt to clear the way for sub contracting public health to NGOs.
The Draft proposes to empioxuser feejjn pubiicAosQM-m^^
albeit couched in the usual
sugar coaling of ii being introduced for those who can pay. Global
experience of user fees at any level shows that they serve only one purpose
- to drive out the poor mid the indigent. Aity-meiitiei^of Proposal of user fees in a
Health Policy Draft is objectionable, and untenable. The section that
suggests targeting of pi iiiiaiy health cai'o for resource allocation needs to
be read alone with this prescription tor introduction of user fees. While
targeting of primary health care is to be welcomed, this should not
constitute an argument for the iegitimisation of the government s retreat
from providing comprehensive and quality secondary7 and tertiary care. The
Draft hints al this possibility in different sections and also hints al
"encouraging” the private sector to occupy the space that would be left vacant
The Draft talks about using Indian health facilities to attract patients
from other countries. It also suggests that such incomes can be termed
'deemed export" and should be exempt from taxes. This formulation draws from
recommendations that the industry has been making and specifically from the
’’Policy Framework for Reforms in Health Care”, drafted by the prime
Minister’s Advisory Council on Trade and Tndustry> headed by Mukesh Ambani
and Kumaraniangalam Dii la Such a proposal, termed by many as ’’health
tourism”, will divert our best resources to serve the interests of the
global health market and create islands of brain and resource drain within
the countrv. it is apronosal that needs to be rejected outright. Pl. see my coyerjngjetter. Anant.
The Draft
also, presumably drawing inspiration from the same report;- talks of
encouraging "the setting up of private insurance instruments for increasing
the scope of the coverage of the secondaiy and tertiary sector under private
health insurance packages”. Further, there are repeated references in the
Draft about "valuable” vouti ibutions made by the private sector and the need
to "encourage” more such contributions. While the Draft is repeatedly
critical of ths public health system (justifiably so) there is not a single
I
I
I
I i
♦
word of criticism of the ills of the unregulated private medical care system, though
reierence is made io the need io develop reguiaiory norms.
tHipoiiaiti Coftccriis igfrored) ( THIS SECTION HAS BEEi> SHIFTED
Gthvr iinpoitatrrvOHvUfHS wv vluicf ignored-or referred to only in passing.
4he4)t^-has-artettF4me-section on women-s-health, without any specific
proposals being spelt out. Child health is not even afforded a separate
section; and is deatf-with through passing-references. It is silent on child
nutrition-in-spite- of the shrmiefulfact-that-ahalfefclHldrenbel oYvfai'e
malnourished inTndia- a dubious distinction that India shares with only
one ether country (Bangladesh) in the world.
Tn the tffea of medical education the Draft talks of the need to intredtiee
postgraduate courses m -family medicine”. Th@4oag-standing position of the
he alth-meveme nt -has 4>ee n-to -I imit-sp eci atrsation- and- reori entamdereraduate
eduo^ion-to equip-doctors in-a-manner thaTthey^are aMcTo better uddress
neaith needs or-the common people. Such a purpose cannot be served by just
total ictuk ui undei slctitding legtti ding dte -need to vreuie a medium ettuuctiten
Qy^enA-Arie«^d-^^he-aeeds-^pFi-mary<4ir-a;-afKl-instead-is-steepe<l-4n-the
biftS Ox UiOtUi
I
I
I
I
I
I
I
I
I
I
I
I
I
I
viciTigi-trtiovM iiUciiili UciiU. Oil mC OtllCl liUriid it la viililuij
siTent-abnut-thedrane 04-private-ffledical colleges and the need to restriet
and regulate these institutions.
Tlic sectiemon P.csearch harps on -frontier areasLLand-medi£-al-Fes^'ch7
There is no understanding oi the necessity to initiale-and sustain research
nn public h^nlth-There no mention of the necessity-to regulate medioal
research-aiid-kr -develop- ethieal -vriterrir tn-ihis-fegard- The-impae t -oTTRIPS
is discussed in terms-of possible impact on drug prices, but there4s-no
mention of the crippling effect of TRIPS-on medical research.
sc ( TIBS SECTION BLAS BEEN SHIFTED
As-methkrned-earMer- the-Draft is-most-eloquent-where it is oilefit-The
Draft, very uoitseiousiy, abjitfes die words uoinprehensive -and universal
heakh-et»?e^T^eeW-a9t4he-:NW~lW%4^-widriTRd^aris--eemmftted-te
attaining the goal of ^Health for /ill by the Year 2000 A.D.” through-the
universalqirovision ot comprehensive primary health care senices-.-Ihe new
Draft, thus, repudiates a fundamental concept of theNHP 1983 and the Alma
!
I
I
I
I
I
I
I
i
I
I
I
II
I
I
i
-'I
Ata declaration. It-is also canspicueusly silent erHtfte-^village he^th
worker - the iirst-coffiacr^mthe-primai^v heaitn-e^e^ystem. in-other
tba-Prail-provid?s a fi-nmewori^-forTh? drsmantlmg of
the whole- eoficept-of-prifnaiy hettitii cure. Signiiicuiitiy -j-tlie-sectionon
A
V
A
A
•*
I
l
I
I
|J1 llllcU Y llVClllll ViUV JjJ’kJtVlllT
The Draft lias nothing substantive to say of the population control
pr-egmffiffie, whicft-the-fteafth movement has long held to constitute a major
drain-enrprimary health care. It-repeats the -usual sophistry that advances
in public neunn nave been nuiiiiied by increase in popuiaiiofl7-i-his remm
I
P4^r4*dieta 9II evidt?nre ^vnilnhli? 9(yog-the
which show thnt
pfpimiitOtr s tub
dmnttttivin-or-veFtuiih SOviO-vvVriui HiC
standards and do not preoede-the-nh
I
the- Draft- ts or-aetieaftv-sd ent-ah out-p harmaeeuticals-and-tftett- impact -on
heaftft-caro--^eFe4:y7-aeeeptin^thai-it-has-aoyele-m4bFmHlation-ei-the
drug policy, this is even more surprising giventhe tact thi»-anew4.4ru^
Poli^-is-^eing-discHss^-d by th?--ludii^try Ministry today- and reports-about
die policy mw-been-uvaitubie for some Hiontiis. The-fiew policy,- it is
hobove^rwidy-eoommen4-fBrthe^rola¥fltio^f-pri<?o-rHidproductfen
vontrola.
we-to uiidviStaiid that thv NT IP believes-that increased drug
i
sector?
In brief, the Draft identifies many_of the_^0SS_deficie^les_o£lhe_ej:Lsting_he^^
proposes a substantial rise in central government expenditure on iieaiih care and has some other
nncitive
1iV>=» tbA
regulation of the Private sector However it c on sti tn te s a return
cui abdiiuoiiiiiCiit Qi
iru m -rii iaiu A id dgvicu diiuii, and legitimises, eiiiidiices lUitiiei pi 1 v aiiSdtiuii
of the health sector n return to-the
concept vfwuuallj diivctod iiistitutioa based health care, much of the
a tous-rhetortc- notwfthstandi-n gr 44-aHowed 4o- be- enshrined- rn-rts-present
fermpth-•■NJSLe-afi-bc--usc-d-as a toe! to kgitimisapriA-atisatioH ef the
health sector.
nnnnnnnnnnonnnnnnonnnnnnnnnnnnnnnaonnnononnnonnnnnonnoonnnanD
□ uuuuauDuuuuuuuuL.iuuuuuuuuaauaauuuuuuLiuLJUULjuLJuuuuuuLJLjbaL.juDaDaa
□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□UUUUUUUUUUUOUUUD
I
I
I
I
I
I
■
t
";1
rpha-ncc] Fw: Comments on the National Health Policy 2001
■
.
Subject: [pha-iicc] Fw: Comments on the National Health Policy 2001
Date: Thu, 27 Sep 2001 23:25:05 +0530
From: "P^avi Duggal" <raviduggal@vsnl.com >
Organization: Home
Tn* <PWA-nrr^vahnnarnnnc rnm>
W•
a.
A A
A.
AAW* W
V
• «ar
4LA4U
Dear Al!
My response on the NHP 2001 which i have sent to the Ministry is attached
Ravi uuggai
PS on behalf of CEHAT Anant has sent comments on the elaborate and meticulous draft worked out by Amit.
— Original Message —
From: Ravi Duonal
To: aeabop@nb.nic. in
C^. secyriith@nb.nic.in . suiau idfdo@vsi ii.cuin , jssf@nb.nic.in
sent: Thursday, Septembers?, 2001 11:22 PM
Subject: Comments on the National Health Policy 2001
Tvi Javed ChOudiiafy and Sujaum ixav
As requested by you a copy of my comments on the NHP 2001 is attached See attached MS-Word file
Ravi Dugga!
visit the following websites on health and health care in India:
www.uetiai.oiq
www.mtcmdia.org
: ¥«awt iari wq» oiwuwi:
ADVERTISEMENT
1
I
I
I
I
I
irr witw.wrMM Hawrir;
9
imp’
lift.*’
_u_________________________________
To unsubscribe froiii this group, 5end an eiiiail to:
pna-ncc-unsubscrioeisegroups . com
Your use or Yahoo! Groups is subject to the Yahoo! Terms or Service.
9/28/01 11:3
1 of 2
fnha-nrrl Fw Comments on the National Health Policy 2001
3^
^>w
o '
*
I-
«1=4 a ppqno’NTC’i? to tt w? pxp ajtt NATIONAL HEALTH POLICY 2001.doc
1“.......
I
!
Name: A RESPONSE TO
THE DRAFT
NATION AT,
HEALTH POLICY
2001.doc
Type: WinWord File
(appiicarion/msword
| Encoding: base64
L
2 of 2
9/28/01 11::
A RESPONSE TO TIIE
DRAFT NATIONAL HEALTH POLICY 2001
Ravi Ouggal, Coordinator.
Centre for Enquiry into Health and Allied Themes (CEHAT), Mumbai
1. INTRODUCTOR.Y / CURRENT SCENARIO
The NHP 2001 begins with some of the recommendations of the NHP 1983 but al! the 4
recommendations listed in para 1.2, i thru iv, in the 2001 policy document are unrealized
nearly two decades later the network ofPHCs do not provide comprehensive primary
health care but only family planning services, selected immunization services and
selected disease surveillance: health volunteers started in 1977 have now disappeared in
most states; there is no organised referral system for the hospitals because the
decentralized care does not meet the health care needs of the masses; and evenly spread
specialty' and super-specialty sendees do not exist, whether public or private they are
located mostly in metro cities or other large cities.
The NHP 1983 had other critical recommendations which the NHP 2001 does not refer to
’Z the establishment of a nationwide network of epidemiological stations that would
facilitate the integration of various health interventions, and
■f targets for achievement that were primarily demographic in nature.
an expansion of the private curative sector which would help reduce the
government's burden,
During the decade following NHP 1983 rural health care received special attention and a
massive program of expansion of primary health care facilities was umrei taken hi the o
and 7lh Five Year Plans to achieve the target of one PHC per 30,000 population and one
subcunti-c per 5000 population. This target has more or less boon achieved, though afew
states still lag behind. However, various studies looking into rural primary health care
have observed that, though the mfrustructire is in place in most areas, they are grossly
underutilised pecause of poor facilities, inadequate supplies, insufficient effective personhours, poor managerial skills of doctors, faulty planning of the mix of health programs
and iack or proper monitoring and evamatory mechanisms, runner, tne system oeing
based on the health team concent failed to work because of the mismatch of training and
the work allocated to health workers, inadequate transport facilities, non-availability of
appropriate accommodation tor the health team and an unbalanced distribution of work
time for various activities. In fact, all studies have observed that family planning, and
more recently immunisation, get a disproportionately large share of the health workers'
effective work-time. (NSS,1987, IIM(A),1985, NCAER,1991, NIRD,1989, Ghosh,1991,
ICMR,1989, Gupta&Gupta,1986, Duggal£Amin,1989, Jesani et.al,1992. Nil,1988,
ICMR,1990)
Among the other tasks listed by the NHP 1983, decentralisation and deprofessionalisation
have taken place in a limited context but there has been no community participation. The
entire burden oi whatever care PHCs and SCs provide fails on the shoulders of lhe ANM
the male health worker is being phased out and the health volunteers are vanishing in
most states. This model of primary health care being implemented in the rural areas has
not been acceptable to the people as evidenced by their health care seeking behaviour.
The rural population continues to use private care and whenever they use public facilities
for primary care it is the urban hospital they prefer (NSS-1987, Duggal & Amin.1989,
Kannan et.al.,1991, NCAER,1991, NC\ER,1992, George et.al.,1992). Let alone
provision of primary medical care, the rural health care system has not been able to
provide for even the epidemiological base that the NHP of 1983 had recommended.
Hence, the various national health programs continue in their earlier disparate forms, as
was observed in the NHP 198? (MoHFWJ983> p 6).
As regards the demographic and other targets set in the NHP 1983, only crude death rate
and life expectancy have been on schedule. The others, especially fertility and
immunisation related targets are much below expectation (despite special initiatives and
resources for these programs over the last two decades), and those related to national
disease programs are also much below the expected level oi achievement, in fact, we are
seeing ?. resurgence of communicable diseases.
However where th a expansion of the private health sector is concerned the growth has
bccii phenomenal thanks to state subsidies in the form of medical education, soft loans to
setup medical practice etc... The private health sector’s mainstay is curative care and this
is growing over the years (especially during the eighties and nineties) at a rapid pace
largely due to a lack of interest of the state sector in non-hospital medical care services,
especially in rural areas (Jesani&Ananthram,1993). Various studies show that the private
health sector accounts for over 70% of ail primary care treatment sought, and over 50%
of all hospital care (NSS-1996, Diiggal#Amin,1989i Kannan et al J991, NCAFP>1991>
George et.al.,1992). This is not a very healthy sign for a country where ovei two-thirds of
the population lives either at or below subsistence levels.
lhe above analysis clearly indicates that NHP 1983 did not reflect the ground realities
adequately. The tasks enunciated in the policy were not sufficient to meet the demands of
lhe masses, especially those residing in rural areas. 'Universal, comprehensive, primary
health care services”, the NHP 198? goal, is far from being achieved.
The NHP 2001 does not even refer to this goal but clearly acknowledges that the public
health caiv system is grossly short of defined requirements, functioning is far from
satisfactory, that morbidity and mortality due to easily curable diseases continues to be
unacceptably high, and resource allocations generally insufficient '7Z
detractfi-om
me quaiiiy ofme exercise if, w hue framing a new policy, it is not ac/mowiedpea mat me existing
miblic health infrastnicti^e isfarfrom satisfactory. For the out-door medicalfacilities in
^cxictcxcc, fielding is generally insafilcicnt; the presence ofmedical and para medicalpersonnel
is often much less man required by me prescribed norms; the availability oj consumables is
frequ.ent.lv nep lipth le: the equipment, in many public hospitals is often obsolescent and unusable:
and the buildings arc in a dilapidated state. In the in-door treatmentfacilities, again, the
equipment is often obsolescent; tne availability of essential drugs is minimal; the capacity ofthe
Mridebate. which leads to over-crowding, and consequentially to a steep
dctc> Oration in th^ quality ofthe services, "(para 2.4.1 NIIP 2001).
The NIIP 2001 needs to be lauded for its concern for regulating the private health sector
through statutory licensing ano monitoring of minimum standards by creating a
regulator^7 mechanism This has been an important struggle of health researchers and
activists to build accountability wiiliin the pi ivate health secioi and we hope the new
policy addresses this issue rigorously Also the express concern for improving healths
statistics, including national accounts, is welcome. A mechanism of assuring statutory
reporting not only by the public system but also the private sector is an urgent
requirement so that health information systems provide complete and meaningful data
2. NIIP 2001 POLICY PRESCRIPTIONS
The main objective of NIIP 2001 is to achieve an acceptable standard of good health
amongst the general population of the country (para 3.1). The goals given in Box IV of
the policy document are laudable but how their achievement in the specified time frame
will happen has not been supported adequately in the policy document. Goal number 10
Increase utilization of public health facilities from current level of <20 to >75%” is
indeed remarkable. What it means is reversal of existing utilization patterns which favour
the private sector. While we support this goal to the hilt we are worried that many
pi escnpuOiis of the policy favour strengthening of the piivate health sector and hence is
contrary to this soal. Hence, all such prescriptions relating to a larger role of the private
health sector must be removed from the policy and instead regulation of the practice and
growth oi me private neaitn sector must oe an important concern for this policy.
vVc suppoit laigci aiiucatiuii uf icsuiiices by the Cunu e and laigei allocations being
recommended for state government* but the states must be given autonomy to use these
rosoui cos as per their own needs and for this the Centre must insist that states formulate
their own health nolicies.
While much more resources need to be allocated for the public health sector, it is also
clear that allocative efficiencies have to be looked into. Since the mid-eighties the
proportion of consumables and maintenance costs and capital costs in the health budget
have been declining and this decline got further hastened after the 5m pay Commission.
The twoNSSO suiveys of 1986-87 and 1995-96 clearly show declines in share of public
sector utilization in both OPD and hospitalization services between the two periods and
this con elates very well w ith reductions seen in expenditures on the non-salary
components of the health budgets. Instead of only talking about proportionate allocations
to the primary, sccondar; and tertiary sectors can we also talk about global budgeting
with assured aiiocaiive ratios, that is budgets being distributed on a per capita basis
(ofcourse with appropriate weightages for sparse and hilly areas) and with clearly worked
out ratios foi line items. Moreover there should be autonomy to local governments to
make their own health programs subject to a review based on local epidemiological
information and facts.
lo illustrate this, taking the CHC area of 150,000 population as a “health district” at
current budgetary levels under global budgeting this “health district” would get Rs. 300
lakhs ( current resources of state and central govt, combined is over Rs.20,000 crores, that
is R.s. 200 per capita). This could be distributed across this health district as follows : P.s
300,000 per bed for die 30 bedded CHC or Rs. 90 lakhs (Rs.60 lakhs fur salaries and Rs.
30 lakhs for consumables, maintenance, POT. etc .) and Rs 4? lakhs per PHC (5 PHCs in
this area), including its sub-ceiiu cs and CIIVs (Rs. 32 lakhs as salaries and Rs. 10 lakhs
for consumables.etc Y This would mean that each PHC would get Rs. 140 per capita as
against less than Rs. 50 per capita currently. In contrast a district headquarter witli
300,000 population would set Rs. 000 lakhs, and assuming Rs. 30U.000 oer bed (for
instance in Maharashtra the current district hospital expenditure is P.s. 150,000 per bed)
the district Hospital too would get much larger resources. 1 o support neaith
neimin^^r^nr, tnonitoring, ^udh statistics etc, each unit would have to contribute 5% of
its budget. Gfvuuisc, dies? Iiguic« nave been worked out witli existing budgctaiy levels
and excluding local government spending which is quite high in larger urban areas. Given
lai ger ivsuui vv allocations as per &c NIIP 2001, the per capita funds available would be
much higher. Such reorganization of fund allocations will remove the inadequacies of the
public health system as highlighted in the policy in pai'as 2.1.1 and 1.1.1.
In para 4.3.1, the NHP 2001 talks about program implementation through autonomous
bodies. The health district” mentioned above could become the basic unit witli a health
committee constituting elected (Panchayat), professional (doctors, nurses etc.) and
consumer representatives into the governing body. This would also mean substantial
pruning of the existing health bureaucracy as the control will now vest with the local
authority and the role of the state health dept, would be overall monitoring and audit as
indicated in the MHP 2001.
in para 4.4.2 the InHP 2001 expresses the practical need io levy reasonable user charges
for certain secondary and tertiary health care services. User-charges is a regressive means
ofiecuverhig costs and given the overall conditions of poverty it is also not an
appropriate means of collecting revenues. Those who have the capacity to pay must be
niadv to pay through other mcaiis. All persons having regular wages/salarics or business
incomes must contribute through pavroll taxes tor health, perhaps something similar to
the profession tax charged in some states. Other ways of generating revenues need to be
considered, sucn as proportion oi turnover of health degrading products like cigarettes,
alcohol, guthka, pan masalas etc., as a health levy earmarked for the Ministry7 of Health.
A health cuss could bu vhargud on hums such as pursunai vuhicius, air-condiiiuiiurs,
mobile phones and other luxuty products, owned houses of a certain tv'pe dimensions, on
land revenues, on polluting industries etc..
While fee MIP 2001 does mention the need to make more provisions for medicines and
other consumables, there is no mention of the Health Dept, plavine a proactive role in the
drug policy. This is a serious anomaly in the h!HP 2001 and the Health dept must exert
its right to determine the drug policy, especially with regard to price control over the
WHO li^t of 300 essential drugs
In reterence to para 4.5.1 with regard to expanding the pool oi medical practitioners
instead of creating liconciatos, qualified practitioners of other systems, nurses,
pharmacists ano other paramedics with certain years (say 8-iO) of experience should be
allowed to complete the MBBS course by recognizing their existing skills for which they
could be given credits and would iiave to do a shoiter course io complete the MBBS
degree.
With regard to regulation of t he private health sector the concern expressed in the NHP
2001 is welcome (para 4.13.1). Th^se is on urgent need to have a comprehensive
legislation on clinical establishments and medical institutions which specifies minimum
standards, good medical practice standards, a mechanism for accreditation, a system of
licensing where me local govt, should have the authority to decide how many
practitioners, hospitals/hosnital beds, diagnostic facilities etc. it needs under its
jurisdiction. Fuiihei renewal ur ductors/hospitals/ diagnostic centres etc., registi aiion and
license should be subject to periodic reviews, including continuing medical education and
upgi dddliun of knuwicdgv aLd facilities. Further, to rationalize health resources the state
should endeavour to organize the entire health care system, public and private, under a
common organized structure through which a regulated public-private mix system can be
evolved, simitar io most countries, which have near universal access health care systems.
S^’ch restructuring of th? health car? system will lead to genuine reforms and establish
gj cater equity in access to health uai c.
Finally, tlic primaiy health care package needs to be cleaily defined. A suggestion of
what this should comprise is given below:
> General practitioner/family physician sendees for personal health care, including
support of paramedics and health volunteers tor preventive and promo tive care.
> First level referral hospital care and basic specialty (genera! medicine, general
surgery, obstetrics and gynaecology, paediatrics and orthopaedic) services, including
dental and ophthalmic sendees.
X Iiiiiiiuiiisaiiun sei vices against vaccine preventable diseases.
> :Maternity
* services for safe pregnancy,
_
......................
safe abortion,
safe delivery and postnatal care.
‘ 4 drugs
4 ; as per accepted
> Pharmaceutical services - supply of only rational and essential
standards.
> Epidemiological sendees
services including laboratory sendees, sur/eillance and control of
major diseases with the aid of continuous surveys, information management and
public health measures.
> Ambulance services.
> Contraceptive sendees
z’ iivdlui vuuCatiOii.
To conclude it is important to emphasise that a health policy, like any other policy, must
make anolitical statement and give evidence oi the backing oi apolitical will, ihere
must of necessity7 bo a preamble, which makes this expression of apolitical commitment
ano in mis case it must be in me context oi health and health care as aright, in me
^hsence ofevpre^sinn of such ? political will there cannot be a policy but only a
stcucinciii ui iiiiciil.
Date: 27th Sentemher. 2001
ravidg££2!@V5i&com ; cckat@vsnI.cGm
CEHA i\
2nd Floor BMC Maternity Home, Military B.oad
iviai ui, Andiiuri East, iviunibui 400 059
PhoneFnv o?ss- website: ww^cehat org
References:
i
jKirw anti b Aeidu, 1969 : Cost of Heaitii Care, Foundation for Research m Coiinnunity Heaitii,
Bombas7
George, Alexet.al.. 1992 : Hoi i^hold Health Expend tine in Madhya Pratesh FRCK Bombay
Ghosh, Basu 1991 : Tlme Utilisation andProdjctisity of Health Manpower, DM, Bangalore
Gupta, JP ad'YP Gupta, 1986 : Study of Sy otcmaiic Aialysis and Functioning of Health Teams at District
and Block Levels, i\iHr vv, New Deiin
1CMR, 1989 : Utilisation oi Health and FP services in Bihar. Gin m at and Kerala. Indan Council at
Med cal Research New Delhi
ICMP, 1990 : Evaluation of Quality of Family Vfelfare Senices at Primaiy Health Centre Level, ICMP,
New Delhi
iiivi(A), 1985 : Siucy of Facility Utilisation andPiogiani ivianagemeiu mFaniily Welfare in UP, MP, Biiiar
(3 Vols.). Public System Group. Indan Institute ot Management. Ahmedabad
Jesani. Amar and S Ananthram.1993 : Private Sector and Privatisation in Health Care Services. FRCH.
Bombay
Jesani, Amai cl.al.,1992 : Slud, of Awdliaiy7&fiihtiwsia^laliai-asl3ti-a,IRCII, Bombay
Kanuaii KP ei.ai., 1991 . Heaitii and Development in Ku al Kaala, Kciaia i^iasna Saiiiiya Parisliad,
liivandum
MoHFW 198^ National Health Policy Govt, of Tnd a. Ministry of Health Family Welfare NewDelhi
MoHF™, 20^1: Draft National Health Pdicy, Mnistiy7 of Health and Family Welfare, NewDelhi
NC/JTx, 1991 . ILzU^Jiold Suviy of Mcdcd Cao, National Council for A^ied Econonic RssKach,
ixewLciiii
NCAEK, 1992 : Kiual Household Heal th Care Need and Availability, NCAEK. NewDelhi
NTRD 1QRQ ■ Health Care Deliwrv system in Rural Areas - A Study of MPW Scheme. National Institute
v*1 nt«noft+ TJxirlit-nlviz-l
NSS 1987 . Mv«11AG ««dUtilLutioa of 2»i?dcal Seniceo, 42nd Round, Report No. 384, National Sample
ouivcy Ctganisatiun, Ncwi>cini
NSb-1996 : Report No. 441,32^Round. NSSO. New Delhi
NTT 1988 Renat of tfe Baseline Siirvev Danida Health Care Project? Vols.. NTT. Bangalore
xr ‘^".2
critique of NHP draft
SuntojesC: Ite [[[pta-nwcjj rnttikpe ©ITNHIP
UDate Mon, 24 Sep 2001 23:35:18 +0530
Fronmio ’’Sundararaman’’ :cerd@satyam.netin>
’ ~
RepEy-Tos ’’Sundararaman” :sundar2@ 123india.com>
T®o <pha-ncc@yahoogroups.com : •9 <ctddsf@vsnLcomDear Amit,
Got your message.. Im only wondering if some of the participants were unable
that. we
to download the message.If so they should send an email to you so that
can send it text . I had some problem downloading it myself.
Good that you could get the draft out so quickly and that you have
incorporated muchof what was discussed in Mumbai. The corrected draft
showing what is cut out and what inclusions are made is a good idea(i..e.. the
second attachment). I seriously suggest that you may submit it to the
minister just like that- except that we mention ONLY those paragraphs where
we suggesting substantial changes.Where we want one or two words changed
u.ike changing "impressive" advances to "modest " advances etc though the
point is well taken we can leave it out. Similarly we can leave out some
points like suggesting a 15% budgetary outlay where we are , to the best of
my knowledge rasing the demand for the first time or where we have no
consensus like a 30 bed hospital for a 30,000 population in urban health.. It
would ony detract from a number of other emphatic points that we are making
. A covering letter would be in order and the first para of the three page
note is excellently drafted and is ideal to begin the covering
letter.However the note itself can do with some more careful drafting and
more understatement,and may refrain, keeping in mind our consistuency, an
agitational turn of phrase.I also think that even as compared to the
corrected draft, the note conveys a diffferent impression on some pointslike the NGO role for example.
A para on food policy ,PDS and the current starvation reports is also . feel
needed.
' am unable to send in a more detailed repsonse as I am travelling the nex._
six days,but these are the main points.
With greetings,
Sundar
■ - - Original Message ---From:; <ctddsf@vsnl. com>
To: <pha-ncc@yahoogroups.com>
Sent: Monday, September 24, 2001 2:59 PM
Subject: [pha-ncc] critique of NHP draft
> Dear friends
> Please find attached three documents in Word format relating to our
response
> to the draft National Health Policy. I am sending them to you as per the
> decision of the Mumbai NWG meeting of the JSA. I have attempted to
> incorporate the substance of our discussions in Mumbai in these drafts.
> The first file -- .NHP.doc -- is a 3 1/2 page overall critique of the
> NHP2001. It can go as our broad response to the Ministry along with ,our
more
> detailed point by point suggestions. It could also be used for our release
> to the Press (possibly after appropriately shortening it)
>
> The second file - health_comfinal.doc -- incorporates all our suggestions
> on the NHP draft. Portions we want deleted are crossed out. and those we
> want incorporated are underlined.
> The third file -- nhp_jsadraft.doc -- is the final draft we are
suggesting,
> incorporating our additions and with the sections we object to, deleted.
Hope this doesn’t sound too complicated!
of 2
pha-ncc] critique of NHP draft
Smiibject: [plha-imcc] endspe offNIKP dirafft
Date: Mon, 24 Sep 2001 14:59:02 +0530 (1ST)
Fnm: ctddsf@vsnl.com
T©: pha-ncc@yahoogroups.com
Dear friends.
Please find attached three documents in Word format relating to our response
to the draft National Health Policy. I am sending them to you as per the
decision of the Mumbai NWG meeting of the JSA. I have attempted to
incorporate the substance of our discussions in Mumbai in these drafts.
The first file -- NHP.doc -- is a 3 1/2 page overall critique of the
NHP2001. It can go as our broad response to the Ministry along with our more
detailed point by point suggestions. It could also be used for our release
to the Press (possibly after appropriately shortening it).
The second file - health_comfinal.doc -- incorporates all our suggestions
on the NHP draft. Portions we want deleted are crossed out, and those we
want incorporated are underlined.
The third file -- nhp_jsadraft.doc -- is the final draft we are suggesting,
incorporating our additions and with the sections we object to, deleted..
Hope this doesn't sound too complicated!
Please send in your comments asap. We need to finalise this by midweek. Do
send your comments, preferably, point wise, indicating the sentence you want
changed and the change you wish to suggest. This would make it easier to
incorporate your suggestions.
Thanks,
Amit
----------------------- Yahoo! Groups Sponsor -------Get your FREE credit report with a FREE Creditcheck
Monitoring Service trial
http://us.click.yahoo.com/MDsVHB/b08CAA/y$SFAA/xYTolB/TM
To unsubscribe from this group, send an email to:
pha-ncc-unsubscribe@egroups.com
Your use of Yahoo! Groups is subject to http;//docs.yahoo.com/info/terms/
Nameo NHP.DOC
NHP.DOC
Type: Winword File (application/msword)
Emcodlnimg: base64
11EALTH~2.DOC
NHP JS~1.DOC
Name: HEALTH~2.DOC
Type: Winword File (application/msword)
Emcodlfiinig: base64
Namme: NHP_JS~1.DOC
Type: Winword File (application/msword)
EiModimg: base64
9/25/0:. 10-3: AM.
of 1
ATT • P-
Response of the
Independent Commission on Health in India (ICHI)
on Draft Hational Health Policy - 2001
"S. ’
'■
L
® I
*
Independent Commission on Health in India
40, Qutab Institutional Area
New Delhi 110 016
Response of the
Independent Commission on Health in India (ICHI)
on Draft National Health Policy - 2001
1.
The Independent Commission on Health in India (ICHI) deliberated on the draft
National Health Policy (NHP - 2001) on 26-27 September 2001. Its initial response
is submitted to the Minister for Health & Family Welfare, Government of India.
2.
At the outset, ICHI welcomes the initiative of the Ministry to put the draft NHP-2001 on
the web for wider public response, though it calls for much wider participatory dialogue.
3.
ICHI would emphasize strongly that the intersectoral aspects of health and the wide
disparities in the health scene in different States requires deeper study, greater use
of empirical evidence and more transparency in discussions at different levels. Such
a process even at this stage can be done in three months or so. ICHI would suggest
that after such consultations a re-draft may be made by end December 2001.
4.
ICHI would like to place its sense of disappointment that the Policy does not posses
an adequately integrated and practical vision focussed on the health needs of the
poor and associated public health investment for their benefit. ICHI has hopes that
such a re-drafted Policy would place health of the poor at the centre and aim at public
health action based on a foundation of equity and effectiveness, particularly with an
experienced public health professional as the Cabinet Minister in-charge of Health.
5.
In the meanwhile, ICHI would offer the following immediate comments outlining
both the strengths and limitations of the draft policy, recognizing that the boundaries
between the two would remain hazy at this stage.
6.
Preliminary Comments
6.1
There is a need for establishing a coherent conceptual framework of health and
wellbeing appropriate to our socio-cultural context within which different elements
and strategies of the Policy can be developed.
6.2
To enable such coherence several key concepts such as Public Health, Primary
Health Care, Equity, need to be defined with greater focus and clarity. Unless this is
done, no new strategy can emerge out of rhetorical use of such terms.
6.3
To our mind, NHP-2001 has no integral link with NHP-1983. The latter was based
on the Alma Ata decision for HFA through the PHC approach. Not only was it an
attempt to found health care on equity and self reliance but it also took into account
earlier ideas from the Shore and other Committees. Such linkage on previous ideas
seems absent now.
6.4
In our view, the draft need not seek to be a de novo Policy. It must aim at being an
updated, revised policy statement taking into account not only the existing health
scene and currently fashionable ideas but also levels of achievements or failure of
earlier strategies and lessons learnt in regard to implementation. Such unfortunately
does not seem to be the case.
1
6.5
Better implementation will call for appropriate reorganization of the public sector
health services at all levels - a task to which NHP-2001 makes no reference. Such
a reorganization must create capacity for imaginative local innovation and gover
nance, greater integration and convergence at all levels. It must also constitute a
legal and managerial mechanism to ensure that resources are properly utilized and
agencies are locally accountable to the public through PRI.
6.6
In India there is a constitutional mandate for the State to protect and promote the
health of its citizens, particularly the impoverished - and increase their access to good
quality health care. The constitutional division of responsibility between the Centre
and the States should be harmoniously used to ensure that centralizing tendencies
do not stifle local initiatives at State and PRI levels. The record of vertical programmes
and central sponsorship of uniform ideas across states deserves to be combated.
6.7
It is noteworthy that we are on the anvil after the 73-74 Amendments to reverse
such centralizing tendencies in health care. Many references in NHP-2001 speak
of a top down approach to planning health action, which will militate against the
opportunities for de-centralization in the health sector. There is no reference to the
type of innovations needed to set up decentralization both for effective delivery of
health care and for accountability to the local public.
7.
Welcome Features in NHP-2001
7.1
ICHI wholeheartedly welcomes the commitment in the draft to an increased public
sector role in health care, needed essentially for the remote, tribal, rural, semi-urban
and marginalized communities. The proposal is welcome for the increase current public
health investment from 0.9% to 2.0% of GDP, with proportionate increases in the Cen
tre and the States within a timeframe. ICHI also welcomes the proposed distribution of
the budget at 55/35/10 ratio with increased proportions going to primary health care.
However, the policy should explore in greater detail the various financing mecha
nisms, including sources of funding, their influence on priority setting and extent of
policy leverage and conditionalities.
7.2
ICHI would like to point out that the shape of the emerging social pyramid in India is
bound to contain a substantial number of poor and near poor population. In the
interest of justice, development and human rights of such population, greater public
investment must oe an integral part of policy in the next few decades.
7.3
ICHI notes also that for the first time the document recognizes the negative impact
u; ;ne forces oi giobalization and economic reforms on the healtn sector. In particu
lar, even though it notes that the document expresses its anxiety over the impact of
TRIPS on drug prices and availability, we fail to find any effective prescription.
7.4
ICHI also welcomes the HRD approach towards a pool of public health personnel
of relevant competence, the emphasis on a sound disease surveillance.system as
part of greater epidemilogical understanding of common diseases in India - an over
due fulfillment of the promise in NHP-1983.
7.5
ICHI also welcomes the recognition in the draft of the importance of converging
services in different health programmes at the ground level. However, the continua
tion of major vertical programmes such as HIV/AIDS, T.B. and Malaria will be a
handicap to effective convergence. ICHI also welcomes the emphasis on essential
drugs policy for rational health care.
2
8.
Limitations of the NHP-2001
8.1
On any realistic assessment, our record of health achievement has been mixed.
There have been some successes in limited fronts but the burden of disease is still
immense is changing and sometimes got polarised. The burden leads to large health
inequalities between socio-economic classes and between regions. Earlier com
mitments by Government under HFA/PHC seems to be totally abandoned in the
present draft. What is critical is the absence of any emphasis on community deci
sion making, community health workers, and affordable and appropriate technol
ogy in medical care to hold down costs.
8.2
The references to equity, primary health care and public health in the policy seem to
be simplistic at many places. They are narrowly conceived as for example equity is
to be redressed only by expansion of the framework of primary health centres and
sub-centres, whereas it is widely known that existing framework is dysfunctional in
many ways. We need a more comprehensive approach, greater intersectoral coor
dination and strengthening the existing primary health care structure to make it op
erational and effective.
8.3
ICHI also regret to note that the crucial determinants of health such as food security
and nutrition, safe water supply and sanitation, environment issues, etc. are tan
gentially referred to as non-health determinants. The impression given is one of
health sector disowning their key interest in the development of such associated
foundations for good health.
8.4
ICHI also feels that having regard to the somewhat ambivalent relationship between
Central and State responsibilities in health sector, the policy does not seek out more
collaborative and balanced policy formulation and create appropriate mechanisms
in this regard. The result would be, ICHI fears, the continuation of the traditional
centralizing tendencies in health policy.
8.5
The privatization of health services seems to be over-emphasized. We always have
had a significant private sector provision in health care in India. But unbalanced
dependence on private sector for curative services would deny access to poor, not
necessarily improve quality nor produce public health gains. Private systems flour
ish best only where minimum needs and social security is already guaranteed.
8.6
Health needs of children, particularly the nutritional gap with almost half the chil
dren undernourished, requires greater emphasis. Convergence of services to chil
dren through ICDS, school health, lifestyle skills education, and ground level health
services need to be emphasized.
In this context, ICHI would like to add that the policy must draw upon the content of
sister policies in education for health sciences (1989), nutrition (1993), drug policy
(1988/1994), elderly persons (1998), etc.
8.7
In the context of an abiding pluralistic system of medical practice in India, where
indigenous systems of medicine account for substantial medical care, there ought
to be emphasis on mainstreaming the indigenous medical systems into public health
services. This is an overdue task, so far performed with adhoc approaches and
some degree of lack of conviction. Since in the perception of people such indig
enous systems play an important role in access to health care, ICHI would plead for
a more proactive policy for integrating and mainstreaming the various systems of
medicine, especially in rural health care.
3
8.8
Nothing has constituted a greater obstacle to people’s health than the decay of
public health and medical institutions set up in the country. The reasons may vary
but long established public sector institutions in public health, tropical diseases or
in drug development have languished for want of sustained nurture by government.
New institutions are no doubt important but ICHI would like the policy to emphasize
the rejuvenation of established institutions in medicine and public health.
8.9
Finally, ICHI must place on record its disappointment about the absence of any
focus on reorganization of health services and infrastructure in the public sector.
Over time, the infrastructure and organization for implementing health policy has
got more and more fragmented. Its leadership has shifted from technical guidance
to administrative leadership, with no balance between the two sources of inputs.
This problem of lack of integration and consequent dysfunctionality in health ser
vices has been the persistent problem in public sector efficiency.
9.
Next Steps - ICHI suggests the following course of action:
9.1
The following reports should be studied and recommendations considered for re
drafting NHP-2001:
• a)
Report of the Independent Commission on Health in India
b)
People’s Health Charter - India - December 2000
c)
Pai Panandikar Report on Reorganization
d)
Dayal Report on Sanitation
e)
Report of the PM’s Economic Advisory Committee on Health Sector (Ambani
Report)
9.2
A small expert group from within government and outside may redraft policy in the
light of the above.
9.3
The revised draft may be put for consultation with States, intersectoral agencies at
the Centre and the States and interested public institutions before being placed
before the Central Council.
9.4
All these processes can be completed within three months in which case the Policy
and its implementation strategies can be accommodated within the 10th Five Year
Plan, starting March 2002.
10.
The Independent Commission on Health in India would be happy to be at the ser
vice of the Minister and Government, in case they can be of help in the process of
consultation and redrafting. India has been a pioneer in many respects, not only
among the developing world, in terms of competence of physicians, experience in
medical practice and education and in the area of focussed public health interven
tions. Given its scale both its success and failure hold lessons for other countries
also. The National Health Policy must, therefore, be drafted in a manner to fulfill
these expectations.
4
Name
Designation
Signature
Mr. Alok Mukhopadhyay
Convenor, Independent Commission on
Health in India and Chief Executive, VHAI
Former Secretary (Health) and Member,
Independent Commission on Health in
India_______________________________
Professor Emeritus, Jawaharlal Nehru
University
ES
Mr. R. Srinivasan
Prof. D. Banerjee
Prof. Ashish Bose
Dr. Shanti Ghosh
Dr. N. S. Deodhar
Dr. H. Sudarshan
Member, Independent Commission on
Health in India_____________________
Member, Independent Commission on
Health in India______________________
Health Consultant and Member,
Independent Commission on Health in
India______________________________
Chairman Task Force & HFW.
Government of Karnataka and Member,
Independent Commission on Health in
India
Prof. G. P. Dutta
Member, Independent Commission on
Health in India and Member, State
Planning Board, West Bengal
Mrs. Rami Chhabra
Member, Independent Commission on
Health in India____________________
Director, National Institute of
Communicable Diseases
Dr. K. K. Dutta
Dr. Amit Ray
Associate Professor of Economics,
Jawaharlal Nehru University
Dr. Mira Shiva
Member, Independent Commission on
Health in India and
Sr. Coordinator, VHAI
J
Invitees
Dr. Thelma Narayan
Coordinator, CMC, Bangalore
Dr. Chandrakant S. Pandav
Faculty Member, Centre for Community
Medicine, AllMS
Place : New Delhi
Date : September 27, 2001
I
[pha-ncc] amended NHP drafts (URGENT)
Subject: [pha-ncc] amended NHP drafts (URGENT)
Date: Fri, 28 Sep 2001 20:11:15 +0530 (1ST)
From: ctddsf@vsnl.com
To: pha-ncc@yahoogroups.com
Friends z
You would have all received the comments on the draft critique of the
NHP2001, a detailed one by Anant and one from Sunder. I have incorporated
these into the drafts -- i.e. the brief overall critique, and the detailed
critique (both attached). The one place where I have retained the earlier
formulation is regarding budget allocation by States. If we are committed to
5& of GDP on health, the money has to come from somewhere, and if we mean
almost a quadrupling of the present level of investment (in GDP % terms) it
would mean more than a doubling of allocation in the budget (in % terms).
I need a quick response, Can I send this to the Ministry by email along with
the annexure sent by Anant and a copy of the Peoples Health Charter?
We can follow this up by sending copies by post to the Ministry and to the
Health Minister, and also seek an appointment with the Minister to hand over
our comments and discuss the same with him.
Also if the drafts are okayed, the 3 page critique can be used by State
organisations and members of JSA for drafting their release to the Press.
This should be a co-ordinated excercise, preferably on the same day all over
the country. Can we decide on the date for this too?
Do let me know if this is OK.
Thanks
Amit
Yahoo! Groups Sponsor
FREE COLLEGE MONEY
CLICK HERE to search
600,000 scholarships!
http://us.click.yahoo.com/uj OgTC/4m7CAA/ySSFAA/xYTolB/TM
To unsubscribe from this group, send an email to:
pha-ncc-unsubscribe@egroups.com
Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
1 of 1
Qfincri~i.doc
Name: FINCRI~1.DOC
Type: Winword File (application/msword)
Encoding: base64
Qfincom.doc
Name: FINCOM.DOC
Type: Winword File (application/msword)
Encoding: base64
9/29/01 11:12 AM
Draft NHP, 2001 - a Brief Critique
The National Health Policy Draft has finally been released by the Ministry of Health and Family Welfare,
early this month. The Draft is available on the website of the ministry, which says that comments on the
Draft will be entertained for a month. We would first like to register our protest regarding the arbitrary
manner in which this policy is sought to be finalised. The last Health Policy document by the government
was released in 1983. We appreciate that in this intervening period developments in the socio-economic
and political spheres, both within and outside this country, would necessitate the formulation of a new
policy. But one would have assumed that such a process would involve wide ranging discussions at all
levels. Moreover, as the Draft itself repeatedly states, Health is a State subject as per our Constitution.
From all accounts the State governments have not been involved in the process of drafting, nor has the
Central Council of Health and Family Welfare been consulted (which is the apex body that has
representatives from all State Health Departments). And now, just one month is being provided to give
comments on a policy that is being drafted after 18 years! Moreover, a policy that reportedly has been at
the drafting stage for three years!
Eloquent Silence
The Draft is most eloquent where it is silent. It completely omits the very concept of comprehensive and
universal health care. In contrast, the NHP 1983 had said: “India is committed to attaining the goal of
“Health for All by the Year 2000 A.D.” through the universal provision of comprehensive primary health
care services”. The Draft, thus, departs from the fundamental concept of the NHP 1983 and the Alma Ata
declaration. It is also conspicuously silent on the village health worker - the first contact in the primary
health care system. By its silence, the Draft provides a framework for the dismantling of the whole
concept of primary health care. Significantly, the section on policy prescriptions in the Draft is entirely
silent on the content of the primary health care system.
The Draft has nothing substantive to say of the population control programme, which the health
movement has long held to constitute a major drain on primary health care. It repeats the usual sophistry
that advances in public health have been nullified by increase in population. This refrain contradicts all
evidence available across the globe, which show that population stabilisation follows attainment of certain
socio-economic standards and do not precede them.
The Draft is practically silent about pharmaceuticals and their impact on health care - thereby accepting
that it has no role in formulation of the drug policy. This is even more surprising given the fact that a new
Drug Policy is being discussed by the Industry Ministry today, and reports about the policy have been
available for some months. The new policy, has reportedly recommended further relaxation of price and
production controls. Are we to understand that the NHP believes that increased drug prices and non
availability of essential drugs have no impact on the health sector?
Important Concerns Ignored
Other important concerns are either ignored or referred to only in passing. The Draft has a four-line
section on women’s health, without any specific proposals being spelt out. Child health is not even
afforded a separate section, and is dealt with through passing references. It is silent on child nutrition in
spite of the shameful fact that a half of children below 5 are malnourished in India — a dubious
distinction that India shares with only one other country (Bangladesh) in the world.
In the area of medical education the Draft talks of the need to introduce postgraduate courses in “family
medicine”. The long-standing position of the health movement has been to limit specialisation and
reorient undergraduate education to equip doctors in a manner that they are able to better address health
needs of the common people. Such a purpose cannot be served by just introducing another specialty
called family medicine. The Draft betrays a total lack of understanding regarding the need to create a
medical education system oriented to the needs of primary care, and instead is steeped in the bias of urban
specialist-based health care. On the other hand it is entirely silent about the bane of private medical
colleges and the need to stop the setting up of new private medical collegesand regulate these institutions.
The section on Research harps on “frontier areas” and medical research. There is no understanding of the
necessity to initiate and sustain research on public health. There is no mention of the necessity to regulate
medical research and to develop ethical criteria in this regard. The impact of TRIPS is discussed in terms
of possible impact on drug prices, but there is no mention of the crippling effect of TRIPS on medical
research.
Compromise and Contradictions
The Draft appears to be a compromise effort that marries contradictory concerns. Section 2, titled,”
Present Scenario” analyses many of the present initiatives and their deficiencies. Some of the conclusions
drawn in this section are premised on correct assumptions. However, many of these assumptions are
ignored or contradicted in the operative part of the Draft, Section 4, titled “policy prescriptions”. The
Draft makes appropriate references about decentralisation, inadequate funds, non-viability of vertical
programmes, inadequate and dysfunctional infrastructure, etc. in Section 2,However, there are either no
matching policy prescriptions in section 4 or these prescriptions are expressed in vague generalities.Out
of the main policy prescriptions, most relate to encouragement of the private sector and legitimisation of
privatisation of the health care delivery system
Increased Fund Allocation — Too Little and Overdue
A further perusal of the Draft throws up many fundamental concerns. The Draft admits that public health
investment has been “comparatively low”. What it does not admit is the fact that such investment as a
percentage of total health expenditure is possibly the lowest in the world ; that India has the most
privatised health system in the world! The Draft recommends welcome increase in public health
expenditure from the present 0.9% of GDP to 2.0% in 2010. However quantum suggested is too little and
comes very late. It falls far short of the 5% of GDP that has been a long-standing demand of the health
movement and recommended by WHO long back. Moreover the Draft projects that public expenditure in
2010 will be 33% of total health expenditure - up from the present 17%. But even 33% is lower than that
of the average of any region in the globe today — India would continue to be one of the most privatised
health system in the world even in 2010! The Draft is eloquent on the inability of states to increase
expenditure on health care and laments that the allocation by states has in fact decreased in the past
decade. There is a veiled attempt to castigate the states for their inability to increase expenditure. Such
insinuations are uncalled for without a detailed analysis of the manner in which the liberalisation process
has shattered the financial stability of states.
Top-Down Prescriptions
The Draft, for all the rhetoric on community participation, is replete with “top down” prescriptions. While
admitting the wastage involved in running Centrally sponsored and controlled vertical disease control
programmes and envisaging their integration in the decentralised primary health care system, it goes on to
recommend that we would need to retain many of them! All subsequent formulations in the Draft,
especially in the section on policy formulations, assumes the continuance of vertical programmes.
Moreover the Draft repeatedly asserts that the Centre will continue to plan all public health programmes.
The Draft continuously harps on the availability of expertise with the Centre, to justify strong Central
control. It is not clear where the basis of such assertions lie. On the other hand the Draft is delightfully
vague about actual devolution of responsibility and financial powers to Panchayat Raj Institutions (PRIs)
and relocation of accountability to appropriate levels of local self-governments. In the absence of such
clarity there is the danger of the primary health care system becoming a Collector driven exercise, that is
controlled by the Centre - thereby defeating the entire effort at decentralisation.
Prescriptions for Further Privatisation
Numerous formulations in the Draft, in various forms, clear the way for even greater privatisation of the
health care system. The Draft says, k‘the NHP will
suggest policy instruments for implementation of
public health programmes through individuals and institutions of civil society”. This constitutes a veiled
attempt to clear the way for sub contracting public health to NGOs.
The Draft proposes to employ user fees in public hospital, couched in the usual sugar coating of it being
introduced for those who can pay. Global experience of user fees at any level shows that they serve only
one purpose - to drive out the poor and the indigent. Proposal of user fees in a Health Policy Draft is
objectionable. The section that suggests targeting of primary health care for resource allocation needs to
be read along with this prescription for introduction of user fees. While targeting of primary health care is
to be welcomed, this should not constitute an argument for the legitimisation of the government’s retreat
from providing comprehensive and quality secondary and tertiary care. The Draft hints at this possibility
in different sections and also hints at “encouraging” the private sector to occupy the space that would be
left vacant.
The Draft talks about using Indian health facilities to attract patients from other countries. It also suggests
that such incomes can be termed “deemed export” and should be exempt from taxes. This formulation
draws from recommendations that the industry has been making and specifically from the “Policy
Framework for Reforms in Health Care”, drafted by the prime Minister’s Advisory Council on Trade and
Industry, headed by Mukesh Ambani and Kumaramangalam Birla. Such a proposal, termed by many as
“health tourism”, will divert our best resources to serve the interests of the global health market and create
islands of brain and resource drain within the country. The use of domestic facilities for treating patients
from outside the country may be encouraged only if such use is restricted to less than 10% of the facilities
of any institution. The Draft also, talks of encouraging “the setting up of private insurance instruments
for increasing the scope of the coverage of the secondary and tertiary sector under private health
insurance packages”. Further, there are repeated references in the Draft about “valuable” contributions
made by the private sector and the need to “encourage” more such contributions. While the Draft is
repeatedly critical of the public health system (justifiably so) there is nocriticism of the ills of the
unregulated private medical care system, though reference is made to the need to develop regulatory
norms.
In brief, the Draft identifies many of the gross deficiencies of the existing health care scenario, proposes
a substantial rise in central government expenditure on health care and has some other positive features
like the proposed regulation of the Private sector. However, it constitutes an abandonment of the Alma
Ata declaration, and legitimises, further privatisation of the health sector.
[pha-ficc] National Health Policy and People's Health Charter
Subject: [pha-ncc] National Health Policy and People’s Health Charter
Date: Fri, 28 Sep 2001 10:11:27+0500
From: cehat <cehatpun@vsnl.com>
To: pha-ncc@yahoogroups.com
CC: cehat@vsnl.com
Dear All,
Sending all of you a copy of the comparison table between our charter and
NHP-2001. The last time I sent it, the attachment did not come through.
Please write immediately if the same thing happens again. It will be
annexured to the document critiquing the National Health Policy- 2001 and
sent to the government.
Warm regards,
Anant
Yahoo! Groups Sponsor
FREE COLLEGE MONEY
CLICK HERE to search
600,000 scholarships!
http://us.click.yahoo.com/uj OgTC/4m7CAA/ySSFAA/xYTolB/TM
To unsubscribe from this group, send an email to:
pha-ncc-unsubscribeOegroups.com
Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
Qj NHP-comparison-1 .doc
1 of 1
Name: NHP-comparison-l.doc
Type: Winword File (application/msword)
Encoding: base64
9/28/01 7:19 PM
C :\WINDOW S\TEMP\NHP-comparison-16. doc
National Health Policy-2001
A comparison with the People’s Health Charter
Sr.
People’s Health Charter
Introduction- We, the people of India affirm
our inalienable right to and demand for
comprehensive health care that includes food
security;
sustainable livelihood options
including secure employment opportunities;
access to housing, drinking water and
sanitation; and appropriate medical care for all;
in sum - the right to Health For All, Now!
1.
2.
The concept of comprehensive primary health
care, as envisioned in the Alma Ata
Declaration should form the fundamental basis
for formulation of all policies related to health
care. The trend towards fragmentation of
health delivery programmes through conduct
of a number of vertical programmes should be
reversed. National health programmes be
integrated within the Primary Health Care
| system with decentralized planning, decision
making and implementation with the active
participation of the community. Focus be
: shifted from bio-medical and individual based
measures to social, ecological and community
• based measures.
The primary health care institutions including
trained village health workers, sub-centers, and
the PHCs staffed by doctors and the entire
range of community health functionaries
including the ICDS workers, be placed under
the direct administrative and financial control
NHP- 2001
The Health Policy does not state at the outset, what is
essential for good health, and wherefor we are headed
by way of this policy.
■
Alma Ata Declaration not mentioned
4.3 DELIVERY OF NATIONAL Pl BLIC HEALTH
PROGRAMMES
4.3.1 NHP-2001, envisages a key role for the Central
Government in designing national programmes with
the active participation of the State Governments.
Also, the Policy ensures the provisioning of financial
resources, in addition to technical support, monitoring
and evaluation at the national level by the Centre.
However, to optimize the utilization of the public
health infrastructure at the primary level, NHP-2001
envisages the gradual convergence of all health
programmes under a single field administration.
Vertical programmes for control of major diseases like
TB, Malaria and HIV/AIDS would need to be
continued till moderate levels of prevalence are
reached. The integration of the programmes will bring
about a desirable optimisation of outcomes through a
convergence of all public health inputs. The policy
also envisages that programme implementation be
effected through autonomous bodies at State and
district levels. State Health Departments’
interventions may be limited to the overall monitoring
of the achievement of programme targets and other
technical aspects. The relative distancing of the
programme implementation from the State Health
Departments will give the project team greater
operational flexibility. Also, the presence of State
Government officials, social activists, private health
professionals and MLAs/MPs on the managemer^
boards of the autonomous bodies will facilitate wellinformed decision-making.
4.6
INSTITUTIONS
4.6.1 NHP-2001 lays great emphasis upon the
implementation of public health programmes through
C:\WINDOWS\TEMP\NHP-comparison-16.doc
of the relevant level Panchayati Raj local self Government institutions. The structure of
institutions. The overall infrastructure of the the national disease control programmes will have
primary health care institutions be under the specific components for implementation through such
control of Panchayats and Gram Sabhas and entities. The Policy urges all State Governments to
provision of free and accessible secondary and
tertiary level care be under the control of Zilla consider decentralizing implementation of the
Parishads, to be accessed primarily through programmes to such Institutions by 2005. In order to
achieve this, financial incentives, over and above the
referrals from PHCs.
resources allocated for disease control programmes,
will be provided by the Central Government.
3.
The essential components of primary care
should be:
■ Village level health care based on Village
Health Workers selected by the
community and supported by the Gram
Sabha / Panchayat and the Government
health services which are given regulatory
powers and adequate resource support
■
Primary Health Centers and sub-centers
with adequate staff and supplies which
provides quality curative services at the
primary health center level itself with
good support from referral linkages
A comprehensive structure for Primary
Health Care in urban areas based on urban
PHCs, health posts and Community Health
Workers under the control of local self
government such as ward committees and
municipalities.
■
Primary health care approach not mentioned at all.
4.4 THE STATE OF PUBLIC HEALTH
INFRASTRUCTURE
4.4.1 NHP-2001 envisages the kick-starting of the revival
of the Primary Health System by providing some essential
drugs under Central Government funding through the
decentralized health system. It is expected that the
provisioning of essential drugs at the public health service
centres will create a demand for other professional services
from the local population, which, in turn, will boost the
general revival of activities in these service centres. In
sum, this initiative under NHP-2001 is launched in the
belief that the creation of a beneficiary interest in the
public health system, will ensure a more effective
supervision of the public health personnel, through
community monitoring, than has been achieved through the
regular administrative line of control.
4.9 URBAN HEALT H
4.9.1 NHP-2001, envisages the setting up of an organised
urban primary health care structure. Since the physical
features of an urban setting are different from those in the
rural areas, the policy envisages the adoption of
appropriate population norms for the urban public health
infrastructure. The structure conceived under NHP-2001 is
a two-tiered one: the primary centre is seen as the first-tier,
covering a population of one lakh, with a dispensary
providing OPD facility and essential drugs to enable access
to all the national health programmes; and a second-tier of
the urban health organisation at the level of the
Government general Hospital, where reference is made
from the primary centre. The Policy envisages that the
funding for the urban primary health system will be jointly
borne by the local self-Govemment institutions and State
C:\WINDOWS\TEMP\NHP-comparison-16.doc
and Central Governments.
4.9.2 The National Health Policy also envisages the
establishment of fully-equipped ‘hub-spoke’ trauma
care networks in large urban agglomerations to reduce
accident mortality.
J
Enhanced content of Primary Health Care
to include all measures which can be
provided at the PHC level even for less
common or non-communicable diseases
(e.g. epilepsy, hypertension, arthritis, pre
eclampsia, skin diseases) and integrated
relevant epidemiological and preventive
measures
Surveillance centers at block level to
monitor the local epidemiological situation
and tertiary care with all speciality
services, available in every district.
4.
| A comprehensive medical care programme
financed by the government to the extent of at
least 5% of our GNP, of which at least half be
disbursed to panchayati raj institutions to
finance primary level care. This be
accompanied by transfer of responsibilities to
PRIs to run major parts of such a programme,
along with measures to enhance capacities of
PRIs to undertake the tasks involved.
4.15 NAJlOmiJlISEASON
NETWORK
4.15.1 NHP-2001 envisages the full operationalization of
an integrated disease control network from the lowest rung
of public health administration to the Central Government,
by 2005. The programme for setting up this network will
include components relating to installation of data-base
handling hardware; IT inter-connectivity between different
tiers of the network; and, in-house training for data
collection and interpretation for undertaking timely and
effective response.
4.1
FINANCIAL RESOURCES
The paucity of public health investment is a stark reality.
Given the extremely difficult fiscal position of the State
Governments, the Central Government will have to play a
key role in augmenting public health investments. Taking
into account the gap in health care facilities under NHP2001 it is planned to increase health sector expenditure to 6
percent of GDP, with 2 percent of GDP being contributed
as public health investment, by the year 2010. The State
Governments would also need to increase the commitment
to the health sector. In the first phase, by 2005, they would
be expected to increase the commitment of their resources
to 7 percent of the Budget; and, in the second phase, by
2010, to increase it to 8 percent of the Budget. With the
stepping up of the public health investment, the Central
Government’s contribution would rise to 25 percent from
the existing 15 percent, by 2010. The provisioning of
higher public health investments will also be contingent
upon the increase in absorptive capacity of the public
health administration so as to gainfully utilize the funds.
4.2 EQUITY
4.2.1 To meet the objective of reducing various types of
inequities and imbalances - inter-regional; across the rural
- urban divide; and between economic classes - the most
C:\WINDOWS\TEMP\NHP-comparison-16.doc
cost effective method would be to increase the sectoral
outlay in the primary health sector. Such outlets give
access to a vast number of individuals, and also facilitate
preventive and early stage curative initiative, which are
cost effective. In recognition of this public health principle.
NHP-2001 envisages an increased allocation of 55 percent
of the total public health investment for the primary health
sector; the secondary and tertiary health sectors being
targetted for 35 percent and 10 percent respectively. NHP2001 projects that the increased aggregate outlays for the
primary health sector will be utilized for strengthening
existing facilities and opening additional public health
service outlets, consistent with the norms for such
facilities.
5.
The policy of gradual privatisation of
government medical institutions, through
mechanisms such as introduction of user fees
even for the poor, allowing private practice by
Government Doctors, giving out PHCs on
contract, etc. be abandoned forthwith. Failure
to provide appropriate medical care to a citizen
by public health care institutions be made
punishable by law.
6.
A comprehensive need-based human-power
plan for the health sector be formulated that
addresses the requirement for creation of a
much larger pool of paramedical functionaries
and basic doctors, in place of the present trend
towards over-production of personnel trained
in super-specialities. Major portions of
undergraduate medical education, nursing as
well as other paramedical training be imparted
in district level medical care institutions, as a
necessary complement to training provided in
medical/nursing colleges and other training
institutions. No more new medical colleges to
be opened in the private sector. No
commodification of medical education. Steps
to eliminate illegal private tuition by teachers
in medical colleges. At least a year of
compulsory rural posting for undergraduate
(medical, nursing and paramedical) education
be made mandatory, without which license to
practice not be issued. Similarly, three years of
rural posting after post graduation be made
compulsory.
7.
The unbridled and unchecked growth of the
commercial private sector be brought to a halt.
Strict observance of standard guidelines for
4.5 EXTTPffiHUVGH
4.5.1 NHP-2001 envisages that, in the context of the
availability and spread of allopathic graduates in their
jurisdiction, State Governments would consider the need
for expanding the pool of medical practitioners to include a
cadre of licentiates of medical practice, as also
practitioners of Indian Systems of Medicine and
Homoeopathy. Simple services/procedures can be provided
by such practitioners even outside their disciplines, as part
of the basic primary health services in under-served areas.
Also, NHP-2001 envisages that the scope of use of
paramedical manpower of allopathic disciplines, in a
prescribed functional area adjunct to their current
functions, would also be examined for meeting simple
public health requirements. These extended areas of
functioning of different categories of medical manpower
can be permitted, after adequate training and subject to the
monitoring of their performance through professional
councils.
4.5.2 NHP-2001 also recognizes the need for States to
simplify the recruitment procedures and rules for contract
employment in order to provide trained medical manpower
in under-served areas.
4.13 ROLE OF THE PRIVATE SIX TOR
4.13.1 NHP-2001 envisages the enactment of suitable
C:\WINDOWS\TEMP\NHP-comparison-16.doc
medical and surgical intervention and use of
diagnostics, standard fee structure, and
periodic prescription audit to be made
obligatory. Legal and social mechanisms be set
up to ensure observance of minimum standards
by all private hospitals, nursing/matemity
homes and medical laboratories. Prevalent
practice of offering commissions for referral to
be made punishable by law. For this purpose a
body with statutory powers be constituted,
which has due representation from peoples
organisations and professional organisations.
legislations for regulating minimum infrastructure and
quality standards by 2003, in clinical
establishments/medical institutions; also, statutory
guidelines for the conduct of clinical practice and delivery
of medical services are to be developed over the same
period. The policy also encourages the setting up of private
insurance instruments for increasing the scope of the
coverage of the secondary and tertiary sector under private
health insurance packages.
4.13.2 To capitalize on the comparative cost advantage
enjoyed by domestic health facilities in the secondary and
tertiary sector, the policy will encourage the supply of
services to patients of foreign origin on payment. The
rendering of such services on payment in foreign exchange
will be treated as ‘deemed exports’ and will be made
eligible for all fiscal incentives extended to export
earnings.
4.13.3 NHP-2001 envisages the co-option of the non
governmental practitioners in the national disease control
programmes so as to ensure that standard treatment
protocols are followed in their day-to-day practice.
8.
A rational drug policy be formulated that
ensures development and growth of a selfreliant industry for production of all essential
drugs at affordable prices and of proper
quality. The policy should, on a priority basis:
Ban all irrational and hazardous drugs. Set
up effective mechanisms to control the
introduction
of
new
drugs
and
formulations as well as periodic review of
currently approved drugs.
Introduce production quotas & price
ceiling for essential drugs
Promote compulsory use of generic names
Regulate advertisements, promotion and
marketing of all medications based on
ethical criteria
Formulate guidelines for use of old and
new vaccines
Control the activities of the multinational
sector and restrict their presence only to
areas where they are willing to bring in
new technology
Recommend repeal of the new patent act
and bring back mechanisms that prevent
creation of monopolies and promote
introduction of new drugs at affordable
prices
4.13.4 NHP-2001 recognizes the immense potential of use
of information technology applications in the area of tele
medicine in the tertiary health care sector. The use of this
technical aid will greatly enhance the capacity for the
professionals to pool their clinical experience.
■ No mention of rationality of drugs here or in the
drug policy
4.23 IMPACT OF GIX)BAUS,U
HEALTH SECTOR
4.23.1 NHP-2001 takes into account the serious
apprehension expressed by several health experts, of
the possible threat to the health security, in the post
TRIPS era, as a result of a sharp increase in the prices
of drugs and vaccines. To protect the citizens of the
country from such a threat, NHP-2001 envisages a
national patent regime for the future which, while
being consistent with TRIPS, avails of all opportunities
to secure for the country, under its patent laws,
affordable access to the latest medical and other
therapeutic discoveries. The Policy also sets out that
the Government will bring to bear its full influence in
all international fora - UN, WHO, WTO, etc. - to
secure commitments on the part of the Nations of the
Globe, to lighten the restrictive features of TRIPS in its
application to the health
C:\WINDOWS\TEMP\NHP-comparison-16.doc
Promotion of the public sector in
production of drugs and medical supplies,
moving towards complete self-reliance in
these areas.
9.
Medical Research priorities be based on
morbidity and mortality profile of the country,
and details regarding the direction, intent and
focus of all research programmes be made
entirely transparent. Adequate government
funding be provided for such programmes.
Ethical guidelines for research involving
human subjects be drawn up and implemented
after an open public debate. No further
experimentation, involving human subjects, be
allowed without a proper and legally tenable
informed consent and appropriate legal
protection. Failure to do so to be punishable
by law. All unethical research, especially in the
area of contraceptive research, be stopped
forthwith. Women (and men) who, without
their consent and knowledge, have been
subjected to experimentation, especially with
hazardous contraceptive technologies to be
traced
forthwith
and
appropriately
compensated.
Exemplary damages to be
awarded against the institutions (public and
| private sector) involved in such anti-people,
unethical and illegal practices in the past.
10.
| All coercive measures including incentives and
disincentives for limiting family size be
abolished. The right of families and women
within families in determining the number of
children they want should be recognized.
Concurrently, access to safe and affordable
| contraceptive measures be ensured which
provides people, especially women, the ability
| to make an informed choice. All long-term,
invasive, systemic hazardous contraceptive
technologies such as the injectables (NET-EN,
Depo-Provera, etc.), sub-dermal implants
(Norplant) and anti fertility vaccines should be
banned from both the public and private sector.
Urgent measure be initiated to shift to onus of
contraception away from women and ensure at
least equal emphasis on men's responsibility
for contraception. Facilities for safe abortions
be provided right from the primary health
[ center level.
11.
i Support be provided to traditional healing
; systems, including local and home-based
| healing traditions, for systematic research and
| community based evaluation with a view to
| developing the knowledge base and use of
these systems along with modem medicine as
4.12 MEDICAL RESEARCH
4.12.1 NHP-2001 envisages the increase in Governmentfunded medical research to a level of 1 percent of total
health spending by 2005; and thereafter, up to 2 percent by
2010. Domestic medical research would be focused on new
therapeutic drugs and vaccines for tropical diseases, such
as TB and Malaria, as also the Sub-types of HIV/AIDS
prevalent in the country. Research programmes taken up by
the Government in these priority areas would be conducted
in a mission mode. Emphasis would also be paid to time
bound applied research for developing operational
applications. This would ensure cost effective
dissemination of existing / future therapeutic
drugs/vaccines in the general population. Private
entrepreneurship will be encouraged in the field of medical
research for new molecules / vaccines.
■
Refer to National Population Policy-2000.
2.26 ALTERNATIVE SYSTEMS OF MEDICINE
2.26.1 Alternative Systems of Medicine - Ayurveda,
Unani, Sidha and Homoeopathy - provide a significant
supplemental contribution to the health care services in the
country, particularly in the underserved, remote and tribal
C:\WINDOWS\TEMP\NHP-comparison-16.doc
j part of a holistic healing perspective.
12.
Promotion
of
transparency
and
decentralization in the decision making
process, related to health care, at all levels as
well as adherence to the principle of right to
information. Changes in health policies to be
made only after mandatory wider scientific
public debate.
13.
Introduction of ecological and social measures
to check resurgence of communicable diseases.
Such measures should include:
areeas. The main components of NHP-2001 apply equally
to the alternative systems of medicine. However, the policy
features specific to the alternative systems of medicine will
be presented as a separate document.
Integration of health impact assessment
into all development projects
Decentralized and effective surveillance
and compulsory notification of prevalent
diseases like malaria, TB by all health care
providers, including private practitioners
Reorientation of measures to check
STDs/AIDS
through
universal
sex
education, promoting responsible safe sex
practices, questioning forced disruption
and displacement and the culture of
commodification of sex, generating public
awareness to remove stigma and universal
availability of preventive and curative
services, and special attention to
empowering women and availability of
gender sensitive services in this regard.
14.
| Facilities for early detection and treatment of
non-communicable diseases like diabetes,
cancers, heart diseases, etc. to be available to
all at appropriate levels of medical care.
15.
Women-centered health initiatives that
include:
Awareness generation for social change on
issues of gender and health, triple work
burden,
gender
discrimination
in
upbringing and life conditions within and
outside the family; preventive and curative
measures to deal with health consequences
of women’s work and violence against
women
Complete maternity benefits and child care
facilities to be provided in all occupations
employing women, be they in the
organized or unorganized sector
Special support structures that focus on
single, deserted, widowed women and
4.17 WOMEN S HEALTH
4.17.1 NHP-2001 envisages the identification of specific
programmes targeted at women’s health. The policy notes
that women, along with other under privileged groups are
significantly handicapped due to a disproportionately low
access to health care. The various Policy recommendations
of NHP-2001, in regard to the expansion of primary health
sector infrastructure, will facilitate the increased access of
women to basic health care. NHP-2001 commits the
highest priority of the Central Government to the funding
of the identified programmes relating to woman’s health.
Also, the policy recognizes the need to review the staffing
norms of the public health administration to more
comprehensively meet the specific requirements of women.
C :\WINDO WS\TEMP\NHP-comparison-16.doc
minority women which will include
religious, ethnic and women with a
different
sexual
orientation
and
commercial sex workers; gender sensitive
services to deal with all the health
problems
of
women
including
reproductive health, maternal health,
abortion, and infertility
Vigorous public campaign accompanied
by legal and administrative action against
sex selective abortions including female
feticide, infanticide and sex pre-selection.
16.
Child centered health initiatives that include:
A comprehensive child rights code,
adequate
budgetary
allocation
for
universalisation of child care services
An expanded & revitalized ICDS
programme. Ensuring adequate support to
working women to facilitate child care,
especially breast feeding
Comprehensive measures to prevent child
abuse, sexual abuse\ prostitution
Educational, economic and legal measures
to eradicate child labour, accompanied by
measures to ensure free and compulsory
quality elementary education for all
children.
17.
18.
' 1.
Special measures relating to occupational
and environmental health which focus on:
Banning of hazardous technologies in
industry and agriculture
Worker centered monitoring of working
conditions with the onus of ensuring a safe
and secure workplace on the management
Reorienting medical services for early
detection of occupational disease
Measures to reduce the likelihood of
accidents and injuries in different settings,
such as traffic and, industrial accidents,
agricultural injuries, etc.
4.21 QCCUPAT1QNAL HEALTH
4.21.1 NHP-2001 envisages the periodic screening of the
health conditions of the workers, particularly for high risk
health disorders associated with their occupation.
The approach to mental health problems 4.10 MENTAL HEALTH
should take into account the social structure in
India which makes certain sections like women 4.10.1 NHP - 2001 envisages a network of decentralised
more vulnerable to mental health problems. mental health services for ameliorating the more common
Mental Health Measures that promote a shift categories of disorders. The programme outline for such a
away from a bio-medical model towards a
disease would envisage diagnosis of common disorders by
holistic model of mental health. Community
general duty medical staff and prescription of common
support & community based management of
therapeutic drugs.
mental health problems be promoted. Services
for early detection & integrated management 4.10.2 In regard to mental health institutions for in-door
of mental health problems be integrated with
treatment of patients, the policy envisages the upgrading of
Primary Health Care and the rights of the
the physical infrastructure of such institutions at Central
mentally ill and the mentally challenged
Government expense so as to secure the human rights of
C:\WINDOWS\TEMP\NHP-comparison-16.doc
persons to be safe guarded.
19.
20.
21.
this vulnerable segment of society.
Measures to promote the health of the elderly
by ensuring economic security, opportunities
for appropriate employment, sensitive health
care facilities and, when necessary, shelter for
the elderly. Services that cater to the special
needs of people in transit, the homeless,
migratory workers and temporary settlement
dwellers___________________________
Measures to promote the health of physically
and mentally disadvantaged by focussing on
the abilities rather than deficiencies. Promotion
of measures to integrate them in the
community with special support rather than
segregating
them;
ensuring
equitable
opportunities for education, employment and
! special health care including rehabilitative
measures.
Effective restriction on industries that promote
addictions and an unhealthy lifestyle, like
| tobacco, alcohol, pan masala etc., starting with
an immediate ban on advertising, sponsorship
and sale of their products to the young, and
provision of services for de-addiction.
(The People \ Health Charter was prepared in consensus by numerous women’s, science,
health groups, people’s organisations, voluntary groups participating in the People's Health
Assembly process. It was endorsed unanimously at the National Health Assembly at Calcutta
held on 31st November and 1st December)
NHP
Subject: NHP
Date: Fri, 28 Sep 2001 13:02:50 +0530
From: Community health cell <sochara@vsnl.com>
To: amit <ctddsf@vsnl.com>, "Sundararaman,T-AIPSN" <cerd@satyam.net.in>,
"pha-ncc@yahoogroups.com" <pha-ncc@yahoogroups.com>,
Anant Phadke <cehat@vsnl.com>
Dear Amit / Sundar,
Greetings from Community Health Cell!
I received all the three drafts of NHP - 2001 critique of NWG / NCC and
not withstanding Sundars and Anants comments most of which I endorse, I
would like to emphasise that you (Amit) have done an excellent job of
putting all our discussions together and then interpreting and
integrating it into the documents circulated. While the press statement
is confrontational as it perhaps should be when such a 'Khichari' draft
is thrust upon us, I think the second document should be sent formally
to the health ministry - Since it clearly indicates the unacceptable
parts and our formulations, without any emotions.
In the light of our
discussions at Mumbai.
I feel my role at present would be to send a
draft of a covering note which we could place as complementary to both
'pressnote' and polciy ciritique in which a dialogue style predominates
I am using Anants and Sundars circulated notes for this.
I also suggest that the table of NHP and Peoples Charter prepared by
Anant be included in the documents sent by us to the ministery..
Thelma attended the VHAI Round table discussions on NHP - 2001 since
Community Health Cell is also an associate of ICHI. As a member of the
drafting committee, she has ensured that the VHAI meeting note also
requests the health ministry to take the Peoples health charter
seriously as a contribution from peoples movements to the policy debate.
The covering note (draft) is being sent separately. I leave on First
October for a two week trip to Europe and so am under terrific pressure
of deadlines. You can further modify the draft and make a final
decision among yourselves. I believe however that while we should keep
the end of the month deadline to submit the first response, we should
also meet the Health Minister and Health Secretary and hand it over
personally as well. Thelma mentioned our meeting to them at the final
session of the VHAI round table so this is awaited. I am sure Amit can
follow this up with Delhi NWG and contacts. Also I believe the final
NHP - 2001 will only be announced by December 2001. So we have time.
With best wishes,
Dr. Ravi Narayan,
Community Health Cell,
JSA-NWG.
1 of 1
9/29/01 12:08 PM
NHP- 2001
Subject: NHP - 2001
Date: Fri, 28 Sep 2001 18:58:32 +0530
From: Community health cell <sochara@vsnl.com>
To: amit <ctddsf@vsnl.com>, "Sundararaman,T-AIPSN" <cerd@satyam.net.in>,
Anant Phadke <cehat@vsnl.com>, Anant Phadke <pha-ncc@yahoogroups.com >
Dear PHA - NCC / NWG,
Further to my communication this morning to all of you enclosed is the
draft of a preamble that should be attached to Amit's very methodically
written note on NHP - 2001. This may be suitably modified with any
comments that you may all have and action taken at the earliest.
All the best,
Dr. Ravi Narayan,
Community Health Cell,
Bangalore.
pl Draft National Health Policy - 2001.doc
1 of 1
Name: Draft National Health Policy - 2001 .doc
Type: Winword File (application/msword)
Encoding: base64
9/29/01 12:00 PM
Response of the National Coordination Committee, of the
Jana Swasthya Abhiyan to Draft National Health Policy - 2001
Preamble
1. We the representatives of the National Networks and associated organisations of the
Jana Swasthya Abhiyan, National Coordination Committee and the state coordinators,
of the JSA state coordination committees met at Mumbai on 17th September 2001 to
discuss and review the draft National Health Policy - 2001 which had been placed on
the website of the Ministry of Health, Government of India to initiate a public
dialogue.
2. We reviewed the document in detail and especially in the context and framework of
the Peoples Health Charter that evolved in the first Jana Swasthya Sabha
(National, Peoples Health Assembly) which was organised by us in December 2000
at Kolkatta as part of our collective commitment to Health for All - Now.
3. This charter represents the first and only consensus of citizens perspectives in the
country, since the Kolkatta meeting was preceded by 16 state conventions, around —
district level conventions, Kalajathas and a peoples block level enquiry process that
covered around a------ blocks. This process was also supported by the evolution of
consensus booklets on Health for All issues and covered the present day context of
Globalisation; Distortions in Primary Health Care; the need for basic needs approach;
the challenges to focus on the marginalised; and the urgent need to confront the
commercialisation of medical and health care, all issues that we expect the
NHP - 2001 to address as well.
4. At the outset we welcome the initiative of the Ministry of Health and Family Welfare,
of putting the draft NHP - 2001 on its website for public debate and dialogue though
we do feel that for a document of this significance and importance a month is too
short a time to do justice to the issues involved.
5. We welcome the following strengths of the Policy Document
a. The acknowledgement with transparency of:
High levels of morbidity and mortality.
Poor functioning of health services.
Gross Underfunding of health services.
b. The acknowledgement of globalisation as a concern with a critical view of
TRIPS and its impact.
c. The Recommendation for the doubling of Central Government expenditure
and the efforts suggested to increase health expenditure by all concerned in
general.
d. The increased proportion of expenditure on Primary Health Care
(55:35:10 formula).
e. The envisaged regulation of the private health care sector.
f.
The concern about public health, capacities ethics, mental health and family
medicine.
6. We are greatly concerned however at the
a. The very vertical, technocentric and fragmented approach to health care.
b. The absence of any links to the commitment of NHP - 83 to Alma Ata
Declaration and the primary health care approach.
c. The complete lack of analysis of why NHP - 1983 goals remained unfulfilled,
d. The absence of any linkage of health policy to the determinants of health water, food, sanitation environment.
e. The absence of any recognition of our distorted development process and its
relationship to evolving morbidly patterns.
f. Total neglect of Nutrition and child health focus with perfunctory reference to
women's health.
g- The absence of any mention of a rational drug policy and the problems of
irrational and unethical prescribing and promotion of medicines.
h. A failure to understand the urgent need for decentralisation and strengthening
of district and panchayat level mechanism.
i. An ambiguity about the urgent need for intersectoral coordination including
the links between health, development and poverty alleviation programmes.
j. The lack of clarity on the urgent imperative of community mobilization and
community participation and a continuation of the benevolent state delivering
health to a passive populace.
k. The lack of clarity of the real crisis of medical education and the continuing
neglect of quality health human power development policies.
1. An uncritical look at the commercial vested interest in the private sector in the
'abundance of ill health' with market economics overshadowing peoples
needs and patients rights.
7. We believe however that this dialogue process can evolve to debate these issues and
look at them with greater policy rigour in the weeks ahead.
8. As a support to this process of dialogue to which we are committed we circulate.
a. A copy of the draft NHP - 2001, redrafted as it were with our own
formulations.
b. A copy of a comparison between NHP - 2001 formulations and what 'citizens'
have expressed as needs and aspirations in the Peoples Health Charter.
c. A copy of the 5 booklet which were part of a massive popular mobilization
process for Health for All in the year 2000.
9. We look forward to an opportunity at the earliest for a representative team from the
Jana Swasthya Abhiyan to be able to present these endorsements and concerns in
person and also discuss our suggestions and the context of the new formulations.
10. We also look forward to a continued dialogue of the JSA - a network of Networks
with the Health Ministry for evolving Health policies and programme initiatives of
the government in the future towards the Health for All - National Goal.
Jana Swasthya Abhiyan - 2001
National Coordination Committees
1. All India Peoples Science Network (AIPSN)
2. All India Drug Action Network (AIDAN)
3. Asian Community Health Action Network (ACHAN)
4. All India Democratic Women's Association (AIDWA)
5. All India Women's Conference (AIWC)
6. Bharat Cyan Vigyan Samithi (BGVS)
7. Catholic Health Association of India (CHAI)
8. Christian Medical Association of India (CMAl)
9. Forum for Creche & Child Care Services (FORCES)
10. Federation of Medical Representatives Associations of India (FMRAI)
11. Joint Women's Programme (JWP)
12. Medico Friends Circle (MFC)
13. National Alliance of People's Movement (NAPM)
14. National Federation of Indian Women (NFIW)
15. National Association of Women's Organisations (NAWO)
16. Ramakrishna Mission (RK)
17. Society for Community Health Awareness Research and Action (SOCHARA)
18. Center for Enquiry into Health & Allied Themes (CEHAT)
19. Center for Social Medicine & Community Health (JNU)
State Coordination Committees
1. Andhra Pradesh
2. Bihar
3. Delhi
4. Gujarat
5. Haryana
6. Karnataka
7. Kerala
8. Madhya Pradesh
9. Maharashtra
10. Orissa
11. Punjab
12. Uttar Pradesh
13. Tamilnadu
14. West Bengal
?
15.
9
16.
?
17.
7
18.
19.
9
20.
9
Contact Address:
ussion at chad
1/7/02 5:23 PM
!
)4Ce[/L Rstjty
Subject: our discussion at chad
Date: Mon, 7 Jan 2002 23:16:10 -0800
From: "subharakhal" <subharaklial@cmcvellore.ac.in>
To: <sochara@vsnl.com>
dear ravi,
thanks for the info about the draft nhp on the net. i was able to arrange a meeting in chad, it was attended by uncle, jp
and krj and the registrars, the rapporteur was yours truly, i am sending the final copy of the letter to the minister by
attachment, the work on the epidemiology manual is going slow.
luv rakhal
Name: draftnhp2001-response.doc
Type: Winword File (application/msword) j
:
Encoding:
base64
..........................................
; j?^ draftnhp2001-response.doc
i.
6l
0^
0
VkM
J o 2_
A
^11 <^1
(y <^y
C^HptO
/<S
L
K>
■
f—
C<^j2^-h^-C> t
LP^lC.
<ZPl
5'
J,
h^p
L
V^> /xr? crv-'
CHC
<■ y
c^>cl p-e<yp^-
fke^-
c-K i^J^-vo-ro-
y-yt-^Av-
ld-&- P^£e>&-
L^-'z^d
lPP>Tc,P
/~P
P'
3 ^c^rko 5^cxz_
ph6
P) c^e,
^C=SL
vcsr-^s-fc^L '
2^x0
$6>
R v <) PcruV*
id -. . . - —
/kuA-
z?> z—i I l/t^~»z~
<^€->75 kz<_5
II
Ko
->F^
<?( ■'I”
ZfP
S
>
^crr-i'c-l 0^0 VLcy.
^CJV-,
Sl^p' C-h-a^^c~-^
yi^o^ v^u2
bC i is
1/8/02 10:09 AM
. T^y
/•
c
y --
/O
G,
,
/o c>
pf/
ZjoA
I
To,
Dr. C.P. Thakur,
Honourable Minister of Health and Family Welfare
Nirman Bhawan,
Maulana Azad Road,
New Delhi.
gubject: Response of the Department of Community Health, Christian Medical
College, Vellore, Tamil Nadu, to the Draft National Health Policy - 2001
Honourable Sir,
I.
1.1. The Department of Community Health of the Christian Medical College
Vellore, met on the 27* of December 2001 to discuss the draft National Health
Policy - 2001 which we obtained from the following website address:
http://mohfw.nic.in/np2001 .htm
1.2. We, the consultants and registrars of the department discussed the document
in light of our nearly 30 years experience in provision of health care and
development activities for the people of Kaniyambadi block, Vellore district.
Throughout our existence we have been inspired by the philosophy of Alma Ata
and then the National Health Policy 1983.
)
1.3. You may be pleased to know that many of the health indicators in our block
fall well below national and state averages. For example, IMR = 40/1000 live
births, Perinatal Mortality Rate = 31/1000, Underfive mortality = 21/1000, MMR
= 60/100,000. Our immunization coverage is 98% - 99% by 1 year of age. These
impressive statistics of course, not only reflect the access to health care in the
block, but overall development, where the people and the department have
worked together, towards the goal of health for all, guided by the principles
enshrined in the National Health Policy 1983.
1.4. Not only have we been providing health care to the people of Kaniyambadi
block but our staff have been actively involved in teaching Community Medicine
for undergraduate and postgraduate medicine and nursing students as well as
Health Management and Epidemiology through various courses both here and
abroad, for students from various medical, paramedical and management streams.
1.5. We have in place in our block, an efficient Health Information System which
provides us with relevant, current, timely and accurate data. The data provided by
this system has been one of the most important things that have helped us evolve
over the years towards the goal of Health For All. Through this we have noted
trends like the shift towards chronic diseases, increasing proportion of accidental
and self inflicted injuries and suicide deaths and a growing geriatric population
with their unique problems.
1.6. It is in the light of this experience, both academic and practical, where we
were inspired by and hold as sacred the principles of the National Health Policy
1983, as well as backed by our own data over the years that we have discussed the
draft.
II
2.1. Any analysis of the present situation will reveal that one of the weakest links
in our health care system is the lack of holistic vision that conceptualizes a
relevant, transparent, responsible, accountable and dynamic system. Our focus
should be the people, especially the marginalized sections, and equity and social
relevance the core principle. Any National Health Policy should clearly provide
such a vision. This vision should permeate every aspect of health care including
Medical Education, Continuing Medical Education, Medical research, Structure
and Administration of the Health Care System and Budgetary Allocation.
2.2. We wish to point out that given the enormous diversity in terms of
geography, culture, traditions and socio-economic backgrounds in a vast country
like India, it will be almost impossible and very naive to expect a single
prescription to be universally relevant. In as much as a National Health Policy
must reflect the philosophy and goals of a people it should explicitly recognize
the importance of State, District and Panchayat level health planning. In other
words the National Health Policy must reflect decentralization to remain relevant.
m
3.1. We welcome the following aspects of the draft NHP-2001
3.2. We strongly welcome the precedent where the draft has been put on the
internet. This will definitely encourage discussion
3.3. The candid recognition of the inadequacy of both the financial allocation as
well as infrastructure of the public health facilities is encouraging.
3.4. The recognition of the need for setting basic standards for practice in private
clinics, hospitals and in the para-medical field timely and crucial.
3.5. The stress on equity and the presentation of disaggregated data to show the
inequity present is progressive.
3.6. The recognition of the importance of specialists in public health and family
medicine and increase in the number of seats for the same is relevant
IV
4.1. We are concerned at certain aspects of the draft NHP-2001
4.2. The complete ignoring of the Alma Ata Declaration and the concept of
comprehensive health care and inter-sectoral coordination, which has been the
bedrock of the health care revolution in the developing countries, and which
reflects a philosophy that is at once relevant, holistic and sustainable, is
concerning.
4.3. The complete ignoring of the Alma Ata makes this document very ahistorical
ignoring the immense contribution India has made in its development. This also
ignores the success of numerous projects, including ours, which have shown huge
improvements in the health of the people, by following its principles. Does the
blank out reflect a change in the vision of the Government? Do the successes
demonstrated mean noticing? Does a failure of the health system automatically
negate the principles on which it was based?
4.4. A reading of the draft seems to reflect a purely biomedical conception of
health. The almost arbitrary’ mentioning of “non-health determinants” and lack of
recognition of the fields of sociology, anthropology, economics and politics in
both under-graduate education and medical research does not reflect the broader
conception of health that has all along been recognized.
4.5. A complete lack of mention of a few topics is also surprising given their
immense past and future importance. Some of the prominent omissions are: child
health, disability, food security, health insurance, the role of VHN/MPHW.
4.6. Regarding the goals set for various time periods, we feel that they are very
unrealistic, especially the following: Eliminate Kala-azar by 2010; Achieve 0
level growth of HIV/AIDS by 2007; Reduce prevalence of blindness to 0.5% by
2010 and Improve nutrition and reduce proportion of LBW from 30% to 10% by
2010. The last goal has been well demonstrated to depend almost completely on
social and economic change - are we really expecting such an overall change?
And if so how?
4.7. The setting of such targets do not reflect the ground realities. Goals should be
reflective of the possibilities given the resources available, and projected to be
available in the time frame given in the policy. Unrealistic goal setting is going to
take us nowhere and may actually be harmful.
4.8. While setting standards in the private sector, hospitals and paramedical fields
has been mentioned, the neglect of corruption in the public sector and unethical
medical practice is very concerning. We would like to add here that it is
important to bring even the practice of Traditional Systems of Medicine under the
purview of standards. These standards of course could be set by the Traditional
Systems themselves.
4.9. Medical ethics is not limited only to molecular genetics and cloning and
actually should pervade every aspect of medical practice, its arbitrary treatment in
the draft is worrying.
4.10.As such the importance given to Traditional Systems of medicine is
inadequate. The mere recognition of TSM practitioners as potential providers in
National Health Programs devalues their services to the people. There is a need
for a holistic approach where all system works together for the mutual benefit of
the people. Treating them in a separate policy is unrealistic as it fragments the
reality in a multicultural society like India.
4.11. The very idea of health services, both allopathic and the traditional systems,
being “sources of income and foreign exchange” is strongly condemned, though it
definitely reflects the unhealthy trend of commercialization and influence of the
market on a basic human right.
V
5.1. Our vision is of a policy which envisions a clear and realistic perspective on
health and development. The policy should be based on the principles of
provision of comprehensive health care that is of the best quality and is accessible
to every citizen of this country at a price they can afford. It includes also active
health promotion, this being the role of every department of the government,
especially the education, human resources, PWD etc., the Health Department
acting like a watch-dog.
5.2. We have a few suggestions
5.3. Public Health Initiatives: These initiatives are conceived in three broad
categories. The presence of a robust and independent Health Surveillance System
which will monitor the Health of the people. This will avoid a clash of interests
when the Health Department has to supervise itself. The Health Surveillance
System should empower the system to use the data and respond appropriately.
The success of the National Polio Surveillance Program in this regard is a case in
point. The other important area is one of Health Promotion in cooperation with all
relevant departments. This should be aimed at creating a whole new generation of
aware and empowered citizens. The mandatory publication of disaggregated data
in the print media, so that the people at large can recognize the inequity and its
distribution and take increasing interest in their own health is one way awareness
may be generated and make the Health Care System more accountable.
5.4. Health Systems: It has been widely recognized that the up-gradation of first
referral units and secondary level care institutions is a definite requirement to
address the needs of a relevant referral system. Referral systems that work are
extremely important to maintain the credibility of any health system. Staff that is
adequately trained and confident must man such centers. There must be constant
accreditation. The staff must be responsible and accountable to the local selfgovernment institutions.
5.5. Medical Education: As recognized the present System of medical education
is producing ill-equipped in the skills required for running Primary Health Care
Centres. Our Under-graduates also lack basic Public Health Skills. Any Medical
Education Policy should address these two aspects. It could be made compulsory
to have two years of experience as a requirement for applicants to various post
graduate courses.
5.6. Research: Research in the Health field should not be focused only on
vaccines and molecules. The fundamental importance of socio-epidemio-cultural
as well as political and economic aspects of health must be emphasized. Research
into various aspects of the Traditional Systems should also be actively
encouraged.
»
5.7. Public Health Cadre: Recognizing the importance of Public Health as a
speciaiaity, there should Pe a cadre similar to IPS, IAS, IPS. Similarly there
should be a cadre for clinical sendee and another for medical education. To be
recognised as a teacher in a medical college, they should have a suitable
postgraduate degree plus a three months training in education technology.
5 R. Monitoring: Robust, transparent and active monitoring systems need to be in
place. This is especially important in the present scenario of increasing corruption
and unethical medical practice.
5.9. Equity: The vision of an equitable society where every citizen has access to
adequate and quality health care and where people are assured of a good quality
of life is probably the foundation and core principle on or around which any
policy should be built.
VII
We again take this opportunity to appreciate your effort to induce a public debate
on the National Health Policy and hope our concerns and suggestions contribute
in the forming of a relevant, people centered and revolutionary health policy.
Yours Sincerely,
Dr. Abraham Joseph
Professor and Head
Hp- 2-A-3
1
ANNEXURE II
CH
Cll NATIONAL COMMITTEE ON HEALTHCARE
’ IhVcXtt’eaMSS9,lndj?n Hea"f’<are S8c,or
recOiT1ni0ndatlons to
the Centre and SLte Governments and other related organisations to
encourage the growth of the Sector.
^a.ions to
To review the status of the existing policy framework with
of a National Health Agenda.
P
•
To review Developmental and Governance aspects of the Healthcare Sector.
•
To promote Corporate Sector participation in the Sector.
’
1° Hi?'OrdlnatJe, With Rnancial Institutions to encourage investment in
Healthcare and Increase their role In promoting the Sector. To attract Foreion
Direct Investments Into the Sector.
y
•
To highlight the Importance of Government’s role in terms of public
investments for the development of the Primary and Secondary Care.
*
’[o strengthen the linkages between Government and the Private Sector
Participants in Healthcars.
*
on fOrmtJ'ate strate9fes to provide a fii’.p to the Sector with special emphasis
Improvement in Quality of Care and Work Force
Mandatory Waste Management Policies
Accreditation of Hospitals
•/ Opening of Health Insurance.
Increased role of Private and NGO Sectors to participate in Preventive and
r romotive Services and In underserved areas.
Budget and Resource allocation for Healthcare in Slates
Management of Health Services
12-51
23-07-01
S 91 080 6644193
REGISTRAR
R.G.U.H.S
003
/
ANNEXURE IH
/
/
CH NATIONAL COMMITTEE ON HEALTHCARE
Suggested Work Plan For 2001-02
Suggested Dates of Committee Meetings:
July 30, 2001
October ,2001
January, 2002
/
April 25, 2002 ( CEOs Policy Forum on Healthcare)
New Delhi
Mumbai
Bangalore
New Delhi
Common for all Committee Meetings:
Special Presentation
Presentation from a consultant or a CEO on related, relevant area
Special Guest
From Government / International expert
Focus Areas:
National Healthcare Policy : Suggestions and Implementation
• Strengthening linkages between the Government and the Private
occtor Participation in Healthcare
• Health Insurance
• Attracting PDFs and interacting with Financial Institutions
• Waste Management & Outreach Programmes
• Create National Health Agenda
RA°n, A,i0,n Tec!lno,o» & T^taology Upgradation in Hospitals
Boost Quality of Healthcare Infrastructure in India.
• Upgrade Quality of Care and Work Force
• Promote India into a Regional Healthcare Hub.
WORK PLAN FOR THE YEAR 200,F0R APPROyAL
(PropoSwoS^X ?s AMexunUf) ‘he C0mmit,e9 for
VW.
5. REVIEW OF THE STATE OF THE INDUSTRY
,he
«—
he Committee may discuss with reference to the following :
Industry Is attachS^ Sector
A Not®
Note on Tax Benefits for
Healthcare
as Annexure IV
o Depreciation
Eq'Jipment - A
is attached as A„nexure. v
□ SHORT TERM
s^ml^"nto^RM^
Is much required for
and immediate implementation. Membe ™ 4 TJ 3'0 f°r its consfderation
taking tnis initiate forward.
" 0 cflsctJSS *he modalities on
a MEDIUM TERM
-
hS,*:
a,°"9 ** ’
WernXaTHeXre'H^
complete sack of such informatm- forfh '^K 6 5 ,s recluired as there is
Committee to discuss.
e
°f the entire Industry. The
° Oe'"i'op™' °< Wodddaaa Health Infrastnrctuta FacRIaa
6. ANY OTHER BUSINESS
7. DATE & VENUE OF NEXT MEETING
Lunch
p
I rA
Meetings with Government:
Call on Minister and Secretary/Joint Secretary, Ministry of Health & Family
Welfare
Minister/Secretary, Ministry of Finance
Chairperson, IRDA
State Health Ministries
Seminars / Workshops:
Interactive Session with Financial Institutions - September 2001, Mumbai
Healthcare CEOs Mission to Singapore coinciding with India Business
Forum - 10 -14 October 2001
Healthcare Summit - February 2002, New Delhi.
Media:
Exclusive briefings to media on important issues
Regular press releases
Press conference for industry response on the National Healthcare Policy
.
/
ANNEXURg V
Depreciation on rnedieal equipment
Many of the state of the art equipments used for medical diagnosis,
tests surgical process etc. contain a substantial part of computer
chip , computer driven process. It is important to note that while
computers are eligible for depreciation @ 60%, normal plant and
machinery is eligible for depreciation @ 25% only.
In view of the dependence on computer
is
computer driven
driven technology,
technology, it
it is
suggested that the higher rate of depreciation of 60% be extended to
medical equipments as well.
ANNEXURE IV
TAX BENEFITS FOR HEALTHC^IRE INDUSTRY
Infraatructure Statiia
Aecordmgiy k will be useful if the healthcare industiy is accorded the
x“ ±xcture indusrand ,he
^^“2:
Sa a 1
to encourase toe participation of the private sector in
the development of healthcare meeting with worid class stlnd^ds
□ Tax holiday under section 80-IA of the Income-tax Act 1961 which
may be 10014 of the profits for 10 consecutive ye^s- As *e
meTelv1’^ hefalt5cai'e ^structure may not be restricted to
merelj setting of the new facilities but may also include
tended
fae!,tiCS' “i8
the benelt
be uxte.ded vnth effect from current financial year for any facility
from3 ri’T °r •er
e1'?1’?000
the 10 year Period may start
^oTolTooo.'
W Was Set~UP or ^edon or
□ In line with the according of- infrastructure status to healthcare
industry, the benefit of exemption under section 10(23G) S Xe
Income-tax Act, 1961 be .also extended so that✓
Infrastructure projects have access to funds at relatively
lower rate of interest;
^auvcry
✓
The exit of any investor resulting in long-term capital gain if
any, is exempt from tax
H
‘ 11
A
■ “7
Jan Swasthya Abhiyan
Chairperson:
N.H.Antia
I 'ice-Chairperson:
D.Banerjee
Convenor:
B.Ekbal
To
Dr.CP.Thakur,
Hon.’ble Minister for Health and Family Welfare
Ninrnn Bhawan,
Maidana Azad Road,
New Delhi
National Co-ordination Committee:
All India People’s Science Network (AlPSN)
All India Drug Action Network (AIDAN)
Asian Community Health Action Network (ACHAN)
All India Democratic Women’s Association (AIDWA)
Bharat Gyan Vigyan Samiti (BGVS)
Catholic Health Association of India (CHAI)
Centre for Community Health and Soc. Medicine, JNU
Centre for Enquiry into Health & Allied Themes (CEHAT)
( hnstian Medical Association of India (CM Al)
Community Health Cell (CHC)
I omni for ( reche and Child Care Services (FORCES)
l ed of Medical Representative Assns. of India (FMRAI)
Joint Women's Programme (JWP)
Medico l ilends Circle (MFC)
National Alliance of People’s Movements (NAPM)
National Federation of Indian Women (NFIW)
National Association of Women’s Organisations (NA WO)
Ramakrishna Mission (RK)
Subject:
Response of the National Coord. Committee,
of the Jana Swasthya Abhiyan to Draft NHP-2001
Honourable Sir,
We the representatives of the National Networks and
associated organisations of the Jana Swasthya Abhiyan.
National Coordination Committee and the state coordinators,
of the JSA state coordination committees met at Mumbai on
17th September 2001 to discuss and review the draft
National Health Policy - 2001 which had been placed on the
website of the Ministry of Health, Government of India to
initiate a public dialogue.
Working Group:
A in 11 Sen Gupta (AlPSN)
Aniitava Guha (FMRAI)
Anant Phadkc (CEHAT)
Balaji Sampath (AlPSN)
Bmayak Sen (NAPM)
Geo Jose (NAPM)
Mira Shiva (AIDAN)
Prem Chandran John (ACHAN)
Ravi Narayan (CHC)
Sarojini.S. (MFC)
Sndip Bhattacharya (AlPSN)
Sudha.S. (AIDWA)
Sundararaman.T. (AlPSN)
Vandna Prasad (FORCES)
Vijaykumar.G. (AlPSN)
Participating Organ isations:
Over 1000 organisations concerned with health care
and health policy from both within and outside
the above networks.
We reviewed the document in detail and especially in the
context and framework of the Peonies Health Charter th.it
evolved in the first Jana Swasthya Sabha (National. Peoples
Health Assembly) which was organised by us in December
2000 at Calcutta as part of our collective commitment to
Health for All - Now.
This charter represents the first and only consensus of
citizens perspectives in the country, since the Calcutta
meeting was preceded by 16 state conventions, around 100
district level conventions, Kalajathas and a peoples block
level enquiry process that covered around a 400 blocks. This
process was also supported by the evolution of consensus
booklets on Health for All issues and covered the present day
context of Globalisation; Distortions in Primary Health Care;
the need for basic needs approach; the challenges to focus on
the marginalised; and the urgent need to confront the
commercialisation of medical and health care, all issues that
we expect the NHP - 2001 to address as well.
Address for Correspondence: c/o Delhi Science Forum, D-158, Lower Ground Floor, Saket. New Delhi -110017
Ph. 6524324 (O), 6862716 (Telfax). Email: ctddsf@vsnl.com.
Co Pondicherry Science Forum, No.46, 2nd Street, P.R.Gardens, Reddiyarpalayam, Pondicherry 605010.
Ph.. 0413-200733 (O), 372939 (R). 251346 (Fax). Email: cerd@satyam.net.in.
At the outset we welcome the initiative of the Ministry of Health and Family Welfare, of putting the
draft NHP - 2001 on its website for public debate and dialogue though we do feel that for a
document of this significance and importance a month is too short a time to do justice to the issues
involved.
We welcome the following strengths of the Policy Document:
• The acknowledgement with transparency of:
1. High levels of morbidity and mortality.
2. Poor functioning of health services.
3. Gross Underfunding of health services.
• The acknowledgement of globalisation as a concern with a critical view of TRIPS and its impact.
• The Recommendation for the doubling of Central Government expenditure and the efforts
suggested to increase health expenditure by all concerned in general.
• The increased proportion of expenditure on Primary Health Care (55:35:10 formula).
• The envisaged regulation of the private health care sector.
• The concern about public health, capacities ethics, mental health and family medicine.
We are greatly concerned however at the:
• The very vertical, technocentric and fragmented approach to health care.
• The absence of any links to the commitment of NHP - 83 to Alma Ata Declaration and the
primary health care approach.
• The complete lack of analysis of why NHP - 1983 goals remained unfulfilled.
• The absence of any linkage of health policy to the determinants of health - water, food, sanitation
environment.
• The absence of any recognition of our distorted development process and its relationship to
evolving morbidly patterns.
• Total neglect of Nutrition and child health focus with perfunctory reference to women’s health.
• The absence of any mention of a rational drug policy and the problems of irrational and unethical
prescribing and promotion of medicines.
• A failure to understand the urgent need for decentralisation and strengthening of district and
panchayat level mechanism.
• An ambiguity about the urgent need for intersectoral coordination including the links between
health, development and poverty alleviation programmes.
• The lack of clarity on the urgent imperative of community mobilization and community
participation and a continuation of the benevolent state delivering health to a passive populace.
• The lack of clarity of the real crisis of medical education and the continuingjieglect of quality
health human power development policies.
• An uncritical look at the commercial vested interest in the private sector in the ‘abundance of ill
health’ with market economics overshadowing peoples needs and patients rights. We believe
however that this dialogue process can evolve to debate these issues and look at them with
greater policy rigour in the weeks ahead.
As a support to this process of dialogue we are attaching the following:
a. A copy of the draft NHP - 2001, redrafted as it were with our own formulations. We have take the
liberty to amend portions of the original draft [crossed out] and add some portions [underlined],
(titled “Amended Draft NHP-2001”).
b. A copy of the Peoples Health Charter adopted at the Peoples Health Assembly in Calcutta on
December 1st, 2000. (Annexure I)
c. A copy of a comparison between NHP - 2001 formulations and what ‘citizens’ have expressed as
needs and aspirations in the Peoples Health Charter. (Annexure II)
We look forward to an opportunity at the earliest for a representative team from the Jana Swasthya
Abhiyan to be able to present these endorsements and concerns in person and also discuss our
suggestions and the context of the new formulations. May we take this opportunity to seek and
appointment with you where we could present our views.
We also look forward to a continued dialogue of the JSA — a network of Networks — with the Health
Ministry for evolving Health policies and programme initiatives of the government in the future
towards the Health for All - National Goal.
Thanking You,
Yours Sincerely,
(Dr.Amit Sen Gupta)
Member. NWG. JSA
C/o Delhi Science Forum
D-158, Lower Ground Floor, Saket.
New Delhi - 110 017
Ph. 6862716, 6524323
• Email: ctddsffg vsnl.com
Attached:
(Dr.B.Ekbal)
Convenor. JSA
Vice Chancellor, Kerala University,
Trivandrum-695034
0471-306634(0)
Email: ekbal@vsnl.com
1) Amended Draft NHP-2001
2) Peoples Health Charter (Annexure I)
3) Comparison between NHP - 2001 and Peoples Health Charter. (Annexure II)
Amended Draft National Health Policy-2001
1. INTRODUCTORY
1.1 A National Health Policy was last formulated in 1983 and since then, there have been very- marked
changes in the determinant factors relating to the heal± sector. Some of the policy initiatives outlined in the
NHP-1983 have yielded results, while in several other areas, the outcome has not been as expected.
1.2 The NHP-1983 gave a general exposition of the recommended policies required in the circumstances then
prevailing in the health sector. Jt laid out the basic philosophy towards the health sector in the following
words: "India is committed to attaining the goal of "Health for All by the Year 2000 A.D." through the
universal provision of comprehensive primary health care services".The noteworthy initiatives under that
policy were :I.
A phased, time-bound programme for setting up a well-dispersed network of comprehensive primary'
health care services, linked with extension and health education, designed in the context of the ground
reality that elementary health problems can be resolved by the people themselves;
ii.
Intermediation through ‘Health volunteers’ having appropriate knowledge, simple skills and requisite
technologies;
in.
Establishment of a well-worked out referral system to ensure that patient load at the higher levels of
the hierarchy is not needlessly burdened by those who can be treated at the decentralized level:
iv.
An integrated net-work of evenly spread speciality- and super-speciality services: encouragement of
such facilities through private investments for patients who can pay. so that the draw on the
Government’s facilities is limited to those entitled to free use.
1.3 Government initiatives in the pubic health sector have recorded some noteworthy successes over time.
Smallpox and Guinea Worm Disease have been eradicated from the country: Polio is on the verge of being
eradicated; Leprosy, Kala Azar, and Filariasis can be expected to be eliminated in the foreseeable future.
There has been a substantial moderate drop in the Total Fertility Rate and Infant Mortality- Rate, but these are
well below the targets set in the 1983 policy. The limited success of the initiatives taken m the public health
field are reflected in the progressive improvement of many demographic ' epidemiological infrastructural
indicators over time - (Box-I).). Malnourishment amongst children, or the prevalence of anaemia in women as seen in the studies done by the NIN - has not decreased.
continue to contribute to a high level of morbidity in the population, even though the mortality rate may have
been somewhat moderated.
The penod after the announcement of NHP-83 has also seen an increase in mortality through distorted
development leading to ‘life-style’ diseases — diabetes, cancer and cardiovascular diseases, vehicular
accidents, and suicides & homicides. The increase in life expectancy has increased the requirement for
geriatric care. Similarly, the increasing burden of trauma cases is also a significant public health problem. To
address concerns regarding the non-attainment of a large number of goals set out in NHP83 as well as the
changed circumstances relating to the health sector of the country since 1983 have generated a situation in
which it is now necessary to review the field, and to formulate a new policy framework as the National Health
Policy-2001.
1.6 NHP-2001 will attempt to set out a new policy framework for the accelerated achievement of Public
health goals in the socio-economic circumstances currently prevailing in the country.
♦
Box-1 : Through The Years - 1951-2000Achievements
' Indicator
; Demographic Changes
[Life Expectancy
[ Crude Birth Rate
i Crude Death Rate
L____ _ ___________ ___ __________ _ _
j IMR________________
| MMR
1951
1981
36.7
54______
33.9(SRS)
12.5(SRS)
110
408
25~
146"
2000
21.0
9J~
64.6(RGI)
26.1(99 SRS)'
8.7(99 SRS) '
70 (99 SRS) '
<60
bZF
[ Epidemiological Shifts
[ Malaria (cases in million)
i Leprosy cases per 10.000 population
Small Pox (no of cases)
Guineaworm ( no. of cases)
Polio
i Infrastructure
I SC/PHC/CHC
Target by 2000
-I
<4
75
38.1
>44,887
725
2.7
57.3
Eradicated
2.2
<74
>39,792
29709
Eradicated
265
57.363
1,63.181
3
| (99-RHS)
; Dispensaries &Hospitals( all)
9209
23.555
'| 43,322 (95-96-
I CBH1)
Beds (Pvt & Public)
117,198
569,495
' 8,70,161
(95-96-CBHI)
’ Doctors(Allopathy)
61,800
2.68.700
5,03.900
(98-99-MCI)
Nursing Personnel
i
18,054
1.43.887
7.37,000
(99-INC)
L
1.4 While noting that the public health initiatives over the years have contributed significantly to the some
improvement of these health indicators, it is to be acknowledged that public health indicators / disease-burden
statistics are the outcome of several complementary initiatives under the wider umbrella of the developmental
sector, covering Rural Development, Agriculture, Food Production, Sanitation, Drinking Water Supply.
Education, etc. Despite the impressive limited public health gains as revealed in the statistics in Box-I. there is
no gainsaying the fact that the morbidity and mortality levels in the country are still unacceptably high. These
unsatisfactory health indices are, in turn, an indication of the limited success of the public health system to
meet the preventive and curative requirements of the general population.
1.5 Out of the communicable diseases, which have persisted over history, incidence of Malaria has staged a
resurgence in the 1980s before stabilising at a fairly high prevalence level during the 1990s. Over the years, an
increasing level of insecticide-resistance has developed in the malarial vectors in many parts of the country,
while the incidence of the more deadly P-Falciparum Malaria has risen to about 50 percent in the country' as a
whole. In respect of TB, the public health scenario has not shown any significant decline in the pool of
infection amongst the community, and, there has been a distressing trend in increase of drug resistance in the
type of infection prevailing in the country. A new and extremely virulent communicable disease - HIV/AIDS
- has emerged on the health scene since the declaration of the NHP-1983.-As there is no existing therapeutic
cure or vaccine for this infeotien7 The disease constitutes a serious threat, not merely to public health but to
economic development in the country. The common water-borne infections - Gastroenteritis, Cholera —
2. CURRENT SCENARIO
2.1 FINANCIAL RESOURCES
The public health investment in the country over the years has been comparatively low one of the lowest in
the world. Worse still, during the decade of the nineties, as a percentage of GDP, it has declined from 1.3
percent in 1990 to 0.9 percent in 1999. The aggregate expenditure in the Health sector is 5.2 percent of the
GDP. Out of this, about 2014 percent of the aggregate expenditure is public health spending, the balance
being out-of-pocket expenditure. It would not be wrong to say that the system for medical care in the country
is the most privatised system anywhere in the world. The central budgetary allocation for health over this
penod. as a percentage of the total Central Budget, has been stagnant at 1.3 percent, while that in the States
has declined from 7.0 percent to 5.5 percent. The current annual per capita public health expenditure in the
country' is no more than Rs. 160. Given these statistics, it is no surprise that the reach and quality of public
health services has been well below the desirable standard. Under the constitutional structure, public health is
the responsibility of the States. In this framework, it has been the expectation that the principal contribution
for the funding of public health services will be from States' resources, with some supplementary input from
Central resources. In this backdrop, the contribution of Central resources to the overall public health funding
has been limited to about 15 percent. In recent years there has been a major squeeze on the fiscal resources of
State Governments. T-he-fiscal resources-of the State Governments are known to-be very inelastic. This itself is
reflected in the declining percentage of State resources allocated to the health sector out of the State Budget. If
the decentralized pubic health services in the country are to improve significantly, there is a need for injection
of substantial resources into the health sector from the Central Government Budget, and a reversal of this
above trend. This approach, despite the formal Constitutional provision in regard to public health, is a
necessity if the State public health services - a major component of the initiatives in the social sector - arc not
to become entirely moribund. The NHP-2001 has been formulated taking into consideration these ground
realities in regard to the availability of resources.
2.2 EQUITY
2.2.1 In the period when centralized planning was accepted as a key instrument of development in the country,
the attainment of an equitable regional distribution was considered one of its major objectives. Despite this
conscious focus in the development process, the statistics given in Box-II clearly indicate that attainment of
health indices have been very uneven across the rural - urban divide.
Box II : Differentials in Health Status Among States
Population
BPL (%)
Sector
IMR/
Per
1000
Live
Births
(1999SRS)
1 India
Rural
Urban
• Maharastra
Lakh
(Annual
Report
2000)
Malaria +ve
Cases in
year 2000
(in
thousands)
Leprosy
cases
per
10000
popula
tion
(<-2SD)
94.9
47
27.09
75
103.7
49.6
23.62
44
63.1
38.4
J
408
3.7
J
2200
I
J
J
i ____
J
Low
Performing
' States
I Orissa
j
! Bihar
Rajasthan
F
J
I MP
%of
Children
Under 3
years
MMR/
if
{"tn
Tp
per 1000
(NFHS
H)
70
J States
Kerala
Weight
For Age-
26.1
; Better
Performing
j______
^Mort
ality
12.72
14
18.8
27
87
0.9
5.1
25.02
48
58.1
50
135
3.1
138
21.12
52
63.3
37
79
4.1
56
47.15
97
104.4
54
498
7.05
483
42.60
63
105.1
54
707
11.83
132
15.28
81
114.9
51
607
0.8
53
31.15
84
122.5
52
707
4.3
99
37.43
90
137.6
55
498
3.83
528
Also, the statistics bring out the wide differences between the attainments of health goals in the better
performing States as compared to the low-performing States. Even within States, there exist wide disparities
because of uneven development. It is clear that national averages of health indices hide wide disparities in
public health facilities and health standards in different parts of the country. Given a situation in which
national averages in respect of most indices are themselves at unacceptably low levels, the wide inter-State.
and intra-state disparities imply that, for vulnerable sections of society -in several States, access to public
health services is nominal and health standards are grossly inadequate. Despite a thrust in the NHP-1983 for
making good the unmet needs of public health services by establishing more public health institutions at a
decentralized level, a large gap in facilities still persists. Applying current norms to the population projected
for the year 2000, it is estimated that the shortfall in the number of SCs/PHCs/CHCs is of the order of 16
percent. However, this shortage is as high as 58 percent when disaggregated for CHCs only. The NHP-2001
will need to address itself to making good these deficiencies so as to narrow the gap between the various
States, in backward areas in states, as also the gap across the rural-urban divide.
2.2.2 Access to, and benefits from, the public health system have been very uneven between the betterendowed and the more vulnerable sections of society. Vulnerable sections like dalits, tribals, women, children
women, and the disabled are those who have been the most marginalised by the uneven reach of the deliven'
system Thts-is paFticularly true-for women, children and the socially disadvantaged-sections of society. The
statistics given in Box-Ill highlight the handicap suffered in the health sector on account of socio-economic
inequity.
Box-Ill : Differentials in Health status Among Socio-Economic Groups
Indicator
India
Social Inequity
Scheduled Castes
Scheduled Tribes
i Other Disadvantaged
Others
I
Infant
MortaIity/1000
Under 5
Mortality/1000
% Children
Underweight
70
94.9
47
83
119.3
53.5
84.2
126.6
55.9
76
103.1
47.3
61.8
82.6
41.1
2.2.3 II is a principal objective of NHP-2001 to evolve a policy structure which reduces these inequities and
allows the disadvantaged sections of society a fairer access to public health services.
2.3 DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
2.3.1 It is self-evident that in a country as large as India, which has a wide variety of socio-economic settings,
national health programmes have to be designed with enough flexibility to permit the Slate public health
administrations to craft their own programme package according to their needs. Also, the implementation of
the national health programme can only be carried out through the State Governments' decentralized public
health machinery. Smce-.-for-various con si derat ioRS-.-the responsibility of the Central Government in funding
additional public heal th-services-will contmueover a period of time, the role of the Central Government in
designing broad-based public health initiatives will inevitably-continue. -Moreover, it has been observed that
the technical-and managerial-expertise for-designing large-span-public health programmes exists with the
Central Government in-a considerable degree; this expertise can-be gainfully utilized in designing national
health-programmes for implementation in-varying socio-economic settings in the states. It is envisaged that
the States will have the primary responsibility of designing and monitoring their health programmes. The
Centre will play a co-ordinating role and provide technical and financial support wherever it is felt necessary.
2.3.2 Over the last decade or so, the Government has relied upon a ‘vertical’ implementational structure for
the major disease control programmes. Through this, the system-has-been able to make a substantial dent in
reducing the burden of specific diseases. However, such an organizational structure, which requires
independent manpower for each disease programme, is extremely expensive, has a low cost-benefit ratio and
is difficult to sustain. In the long run it is a more sustainable option to integrate disease control startegies
within the decentralised primary health care network, linked to adequate secondary and tertiary support
sendees. Over-a long time range, ‘verticaT structures may only be affordable for diseases, which offer a
reasonable possibility of elimination or-eradication in a foreseeable time-span. Vertical programmes may be
considered only as short-term measures, run in a "mission mode" in very exceptional circumstances. In this
background, the NHP-2001 attempts to define the role of the Central Government and the State Governments
in the public health sector of the country.
2.4 THE STATE OF PUBLIC HEALTH INFRA-STRUCTURE
2.4.1 The delineation of NHP-2001 would be required to be based on an objective assessment of the quality
and efficiency of the existing public health machinery in the field. It would detract from the quality of the
exercise if, while framing a new policy, it is not acknowledged that the existing public health infrastructure is
far from satisfactory. For the out-door medical facilities in existence, funding is generally insufficient; the
presence of medical and para-medical personnel is often much less than required by the prescribed norms; the
availability of consumables is frequently negligible; the equipment in many public hospitals is often
obsolescent and unusable; and the buildings are in a dilapidated state or non-existent in a large number of
cases. In the in-door treatment facilities, again, the equipment is often obsolescent; the availability of essential
drugs is minimal; the capacity of the facilities is grossly inadequate, which leads to over-crowding, and
consequentially to a steep deterioration in the quality of the services. The PHCs have primarily become
centres for family planning and immunisation, As a result of such inadequate public health facilities, it has
been estimated that less than 20 percent of the population seeks the OPD services and less than 45 percent
avails of the facilities for in-door treatment in public hospitals. This is despite the fact that most of these
patients do not have the means to make out-of-pocket payments for private health services except at the cost
of other essential expenditure for items such as basic nutrition.
2.5 EXTENDING PUBLIC HEALTH SERVICES
2.5.1 While in the country generally there is a shortage of medical manpower, this shortfall is
disproportionately impacted on the less-developed and rural areas. Further, such shortage is most acute in the
case of para-medical manpower like nurses, health workers and technicians. Because of low returns, private
medical manpower seldom ventures into underserved areas. Even in the public health sector, it has been
difficult to deploy and retain medical manpower in these areas because of the harsh circumstances that obtain
here, including lack of access to even very basic facilities. No incentive system attempted so far, has induced
private medical manpower to go-te-sueh-areas; and,-evefwn-the public health sector it has usually been a
losing battle to deploy-medical manpower in such under-served areas. Only a radical transformation of
publicly funded facilities in less developed areas will facilitate the retention of medical humanpower in these
areas. Alongside this, a large number of public health functions can be entrusted to adequately trained and
suitable remunerated para-medical personnel, including village level health workers. The first contact in the
Primary Health Care system, through trained village health workers chosen by the community, as envisaged in
the NHP83, needs to be strengthened after analysing the earlier weaknesses in the VHW scheme. To pro\ ide
immediately accessible first contact care to all villages, there is no alternative to train a Community Health
Worker in even- village, In such a situation, the possibilit^needs to be examined for entrusting some limited
publk health functions to nurses,, paramedics and other-personnel from the extended health sector after
imparting adequate training to them;
2.5.2 India has a vast reservoir of practitioners in the Indian Systems of Medicine and Homoeopathy, who
have undergone formal training in their own disciplines. The possibility of using such practitioners in the
implementation of State/Central Government public health Programmes, in order to increase the reach of basic
health care in the country, is addressed in the NHP-2001. These practioners will have to be suitably trained.
allowed to use limited number of alopathic drugs for priman health care, but strictly forbidden to go beyond
the medicines and conditions in which they would be given training.
2.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS
2.6.1 Some States have adopted a policy of devolving programmes and funds in the health sector through
different levels of the Panchayati Raj Institutions. Generally, the experience has been a favourable one. The
adoption of such an organisational structure has enabled need-based allocation of resources and closer
supervision through the elected representatives. NHP- 2001 examines the need for a wider adoption of this
mode of delivery of health sendees, in rural as well as urban areas, in other parts of the countn.
2.7 MEDICAL EDUCATION
2.7.1 Medical Colleges are not evenly spread across various parts of the country. Apart from the uneven
geographical distribution of medical institutions, the quality of education is highly uneven and in several
instances even sub-standard. It is a common perception that the syllabus is excessively theoretical, making it
difficult for the fresh graduate to effectively meet even the primary health care needs of the population. There
is an understandable reluctance on the part of graduate doctors to serve in areas distant from their native place.
NHP-2001 will suggest policy initiatives to rectify these disparities.
2.7.2 Certain medical discipline, such as, molecular biology and gene-manipulation, have become relevant in
the period after the formulation of the previous National Health Policy. Also, certain speciality disciplines Anesthesiology. Radiology and Forensic Medicines - are currently very scarce, resulting in critical
deficiencies in the package of available public health services. The components of medical research in the
recent years have changed radically. In the foreseeable future such research will also rely increasingly on such
new disciplines. It is observed that the current under-graduate medical syllabus does not cover such emerging
subjects. NHP-2001 will make appropriate recommendations in this regard.
2.7,3. There has been a mushrooming a private medical colleges in the country. There is a need to standardise
minimum norms regarding facilities that should be available at such institutions. There is also the need to
standardise fee structures in such institutions, No permision should be given to start new nri\ ate medical
colleges, as such collegs have added to the problems of urban concentration, elitist medical culture, unethical
medical practice etc . The NHP2001 issues guidelines in this regard.
2.8 NEED FOR SPECIALISTS IN PUBLIC HEALTH’ AND ‘FAMILY MEDIC INF'
2.8.1 In any developing country with inadequate availability of health services, the requirement of expertise in
the areas of ‘public health’ and ‘family medicine' is ven’ much more than the expertise required for other
specialized clinical disciplines. In India, the situation is that public health expertise is non-existent in the
private health sector, and far short of requirement in the public health sector. Also, the current curriculum in
the graduate / post-graduate courses is outdated and unrelated to contemporary community needs. In respect
of ‘family medicine', it needs to be noted that the more talented medical graduates generally seek
specialization in clinical disciplines, while the remaining go into general practice. While the availability of
postgraduate educational facilities is 50 percent of the total number of the qualifying graduates each year, and
can be considered more than adequate, the distribution of the disciplines in the postgraduate training facilities
is overwhelmingly in favour of clinical specializations. NHP 2001 suggests ways to reorient undergraduate
courses in order to equip medical graduates adequately to face the challenges of priman' care and family
medicine. Such reorientation will seek to ensure that the current craze for specialisation is reversed and more
graduates take up primary care as a long term vocation. In order to address possible "academic stagnation"
among such graduates and to ensure adequate availability of trained humanpower in "public health" and
"family medicine", NHP 2001 makes recommendations for creating and expanding the scope for
specialisation in "public health" and "family medicine". NH-P-2001 examiner, the need for ensuring adequate
availability of personnel with specialization in the ‘public health' and ‘family medicine' disciplines, to
discharge the public health responsibilities in the country.
2.9 URBAN HEALTH
2.9.1 In most urban areas, public health services are ven’ meagre. To the extent that such sen ices exist, there
is no uniform organisational structure. The urban population in the country is presently as high as 30 percent
and is likely to go up to around 33 percent by 2010. The bulk of the increase is likely to take place through
migration, resulting in slums without any infrastructure support. Even the meagre public health services
available do not percolate to such unplanned habitations, forcing people to avail of private health care through
out-of-pocket expenditure. The rising vehicle density m large urban agglomerations has also led to an
increased number of serious accidents requiring treatment in well-equipped trauma centres. NHP-2001 will
address itself to the need for providing this unserved population a minimum standard of health care facilities.
2.10 MENTAL HEALTH
2.10.1 Mental health disorders are actually much more prevalent than are visible on the surface. While such
disorders do not contribute significantly to mortality, they have a serious bearing on the quality of life of the
affected persons and their families. Serious cases of mental disorder require hospitalization and treatment
under trained supervision. Mental health institutions are perceived to be woefully deficient in physical
infrastructure and trained manpower. NHP-2001 will address itself to these deficiencies in the public health
sector. As recent events have shown, private institutions providing mental health care are grossly negligent
and lack basic facilities, The NHP2001 will suggest ways to monitor and regulate such facilities.
2.11 INFORMATION, EDUCATION AND COMMUNICATION
2.11.1 A substantial component of primary health care consists of initiatives for disseminating, to the
citizenry, public health-related information. Public health programmes, particularly, need high visibility at the
decentralized level in order to enhance their have any impact. This task is particularly difficult as 35 percent
of our country’s population is illiterate. The present IEC strategy is too fragmented, relies heavily on mass
media and does not address the needs of this segment of the population. It is often felt that the effectiveness of
IEC programmes is difficult to judge; and consequently, it is often asserted that accountability, in regard to the
productive use of such funds, is doubtful. NHP-2001. while projecting an IEC strategy, will fully address the
inherent problems encountered in any IEC programme designed for improving awareness in order to bring
about-behavioural change in the general population.
2.11.2 It is widely accepted that school and college students are the most receptive targets for imparting
information relating to basic principles of preventive health care. NHP-2001 will attempt to target this group
to improve the general level of health awareness.
2.12 MEDICAL HEALTH RESEARCH
2.12.1 Over the years, medical research activity in the country has been very limited and has been limited to
medical research. In the Government, such research has been confined to the research institutions under the
Indian Council of Medical Research, and other institutions funded by the States/Central Government.
Research in the private sector has assumed some significance only in the last decade. In our country, where
the aggregate annual health expenditure is of the order of Rs. 80,000 crores, the expenditure in 1998-99 on
research, both public and private sectors, was only of the order of Rs. 1150 crores. It would be reasonable to
infer that with such low research expenditure, it would be virtually impossible to make any dramatic break
through within the country, by way of new molecules and vaccines; also, without a minimal back-up of
applied and operational research, it would be difficult to assess and modulate the direction of whether the
health-expenditure in the country is being-incurred through optimal applications and appropriate public health
strategies. The NHP 2001 will encourage greatly enhanced public investment in research, which, as global
experience has shown, is an imperative for giving a thrust to research: while at the same time offering
incentives to the private sector to enage in appropriate and relevant research. Medical Health Research in the
country needs to be focused, first, on optimisation of public health strategies, and also on therapeutic
drugs/vaccines development for tropical diseases, which are normally neglected by international
pharmaceutical companies on account of limited profitability potential. The thrust will need to be on. both,
research on problems of public health, and basic research on development of medical appliances like drugs.
vaccines and diagnostic aids. Research activities will a:so need to focus on the newly-emerging frontier areas
of research based on genetics, genome-based drug and vaccine development, molecular biology, etc. NHP
2001 will also address the issue of ethics in medical research, especially keeping in view recent reports of
violation of ethical norms even in public sector research institutions. It shall recommend setting up of suitable
mechanisms, institutional and legal, for the regulation and monitoring of medical research in both the public
and private sector. NHP-2001 will address these inadequacies and spell out a minimal quantum of expenditure
for the coming decade, looking to the national needs and the capacity of the research institutions to absorb the
funds.
2.13 ROLE OF THE PRIVATE SECTOR
2.13.1 Considering the economic restructuring-underway m the country-, and over the globe, since the last
decade, the changing role of the private sector in providing health care will also have-to be addressed in NHP
2001. At present the private sector is the largest unregulated sector enaged in commercial acti\ ities, and the
issue of its regulation will be addressed by the NHP200I. Currently, the contribution of private health care is
principally through independent practitioners. Also, The private sector contributes significantly to secondary
level care and some tertiary care. Given its large reach and unregulated character, and many reports of
substandard, unethical practices on a wide scale, Wuh-the-iHCFeasing role of private health care, the need for
statutory licensing and monitoring of minimum standards of diagnostic centres / medical institutions becomes
imperative. NHP-2001 will address the issues regarding the establishment of a regulatory mechanism to
ensure adequate standards of diagnostic centres / medical institutions, conduct of clinical practice and delivery
of medical services.
2.13.2 Currently. non-Govemmental service providers are treating a large number of patients at the primary
level for major diseases. However, the treatment regimens followed are diverse and not scientifically optimal,
leading to an increase in the incidence of drug resistance. NHP-2001 will address itself to recommending
arrangements, which will eliminate the risks arising from inappropriate treatment.
2.13.3 The increasing spread of information technology raises the possibility of its adoption in the health
romi
sector. Its role in information
dissemination, monitoring and surveillance, which have a bearing on concerns
related to public health, will be examined by NHP 2001, N-HP-2001 will examine this possibility, especially in
the areas of.
2.14 ROLE OF THE C I\ IL SOC IETY
2.14.1 Historically, the practice has been to implement programmes for primary health care and wtw
national disease control programmes through the public health machinery of the State/Central Governments. Il
has become increasingly apparent that NGOs and other civil society organisations can play an important role
in the monitoring of such programmes and in increasing participation of local communities in planning and
implementation of such programmes. They have also played a major role in community mobilisation, that is
often a major component of any public health programme. Certain components of such programmes cannot be
efficiently implemented merely through government functionaries. A considerable change in the mode of
implementation has come about in the last two decades, with an increasing involvement-of NGOs and other
institutions of civil society. It is to be recognized that widespread debate on various public health issues have,
in fact, been initiated and sustained by NGOs and other members of the civil society. Also, an increasing
coFrtHbtrtion is being made by-such-institutions, m-the-delivery-of different components of public health
services. Certain disease control programmes require close inter- action with the beneficiaries for regular
admimstration of drugs; periodic-earty-'-ing out of the pathological tests; dissemination of information regarding
disease control and other general health-information. NHP-2001 will address such issues and suggest policy
instruments for involvement of civil society institutions in the monitoring of public health programmes
implementation of pub-lie-health-programmes through individuals-and institutions of civil society.
2.15 NATIONAL DISEASE SURVEILLANCE NETWORK
2.15.1 The technical network available in the country for disease surveillance is extremely rudimentary and to
the extent that the system exists, it extends only up to the district level. Disease statistics are not flowing
through an integrated network from the decentralized public health facilities to the State/Central Government
health administration. Such an arrangement only provides belated information, which, at best, serves a limited
statistical purpose. The absence of an efficient disease surveillance network is a major handicap in providing a
prompt and cost effective health care system. The efficient disease surveillance network set up for Polio and
HIA--AIDS-has-demonstrated the enormous value of such-a-pubhc health instrument. Real-time information of
focal outbreaks of common communicable diseases - Malaria. GE, Cholera and JE - and other seasonal trends
of diseases, would enable timely intervention, resulting in the containment of any possible epidemic. In order
to be able to use an integrated disease surveillance network, for operational purposes, real-time information is
necessary at all levels of the health administration. NHP-2001 would address itself to this major systemic
shortcoming in the administration.
2.16 HEALTH STATISTICS
2.16.1 The absence of a systematic and scientific health statistics data-base is a major deficiency in the current
scenario. The health statistics collected are not the product of a rigorous methodology. Statistics available
from different parts of the country, in respect of major diseases, are often not obtained in a manner which
make aggregation possible, or meaningful.
2.16.2 Further, absence of proper and systematic documentation of the various financial resources used in the
health sector is another lacunae witnessed in the existing scenario. This makes it difficult to understand trends
and levels of health spending by private and public providers of health care in the country, and to address
related policy issues and formulate future investment policies.
2.16.3 NHP-2001 will address itself to the programme for putting in place a modem and scientific health
statistics database as well as a system of national health accounts.
2.17 WOMEN'S HEALTH
2.17.1 Apart from poverty, due to the patriarchal nature of our society, the triple burden on women of, child rearing, intensive labour and physical and psychological domestic violence is responsible for the low health
status of Indian women. Further, social, cultural and economic factors continue to inhibit women from gaming
adequate access to even the existing public health facilities. This handicap does not just affect women as
individuals: it also has an adverse impact on the health, general well-being and development of the entire
family, particularly children. NHP-2001-recognises The catalytic role of empowered women in improving the
o\ crall health standards of the community also needs to be recognised. The NHP2001, recognising that issues
related to women’s health are not confined to their role in child bearing or to problems related to the
reproductive tract, sets out policy guidelines that are aimed at enabling women to access the health care
system in much larger numbers.
CHILD HEALTH
Children - who are naturally vulnerable - face a large brunt of problems that relate to the inadequate reach of
public health facilities and services. The are more likely to fall prey to infectious diseases, and infant and child
mortality rates continue to be unacceptable high. In fact in the last few years the disturbing trend of stagnation
or reversal of fall in such mortality rates have been reported. The problem of under nutrition, further, is a very
serious problem among children, given that more than half of children under the age of five are malnourished.
This is a shameful statistic and is a record that is the worst in the world with the exception of Bangladesh. The
NHP2001, taking serious note of these issues, recommends specific child centred initiatives.
2.18 MEDICAL ETHICS
2.18.1 Professional medical ethics in the health sector is an area, which has not received much attention in the
past. Also, the new frontier areas of research - involving gene manipulation, organ/human cloning and stem
cell research — impinge on visceral issues relating to the sanctity of human life and the moral dilemma of
human intervention in the designing of life forms. Besides these, in the emerging areas of research, there is an
uncharted risk of creating new life forms, which may irreversibly damage the environment, as it exists today.
NHP - 2001 recognises that moral and religious dilemma of this nature, which was not relevant even two
years ago, now pervades mainstream health sector issues.
ENSl RING ACCESS TO ESSENTIAL DRUGS, AND RATIONAL DRUG USE
Universal access to life saving medicines is a major imperative for the success of medical intervention^ We
have had the unfortunate precedent of the National Drug Policy being formulated by the Industry Ministn.
with insignificant inputs from the Ministry of Health. The promise in the 1995 Drug policy to set up a
National Drug Authority that would, among other things, co-ordinate between the two ministries in
formulation and implementation of the country's Drug Policy was never implemented with seriousness. Many
elements of the Drug policy like pricing, control on irrational and hazardous drugs, unethical promotion
practices by drug companies, self reliance in drug production, etc, have a bearing on access to drugs.
Considering these the NHP2001 suggests that the nanon's drug policy will reflect adequately concern^ related
to rational and affordable medical care, and to this end suggest guidelines.
2.19 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DRUGS
2.19.1 There is an increasing expectation and need of the citizenry for efficient enforcement of reasonable
quality standards for food and drugs. Recognizing this need, NHP - 2001 makes an appropriate policy
recommendation.
2.20 REGULATION OF STANDARDS IN PARA MEDICAL DISCIPLINES
2.20.1 Though we very much need a much larger number of different types of paramedics, it has been
observed that a large number of training institutions have mushroomed particularly in the private sector, for
several para medical disciplines - Lab Technicians, Radio Diagnosis Technicians. Physiotherapists, etc.
Currently, there is no regulation/monitoring of the curriculum, or the performance of the practitioners in these
disciplines. NHP-2001 will make recommendations to ensure standardization of training and monitoring of
performance.
2.21 OC CUPATIONAL HEALTH
2.21.1 Work conditions in several sectors of employment in the country are sub-standard. As a result of this,
workers engaged in such activities become particularly prone to occupation-linked ailments. The long-term
risk of chronic morbidity is particularly marked in the case of child labour. The medical professionals arc not
well oriented to deal with this scenario. NHP-2001 will address the risk faced by this particularly vulnerable
section of the society.
2.22 PROVIDING MEDICAL FACILITIES TO USERS FROM OVERSEAS
O IT
1 The secondary and tertiary facilities available in the country are of good quality and cost-effective
compared to international medical facilities. This is true not only of facilities in the allopathic disciplines, but
also to those belonging to the alternative systems of medicine, particularly Ayurveda. NHP-2001 will assess
the possibilities of encouraging commercial medical sendees for patients from overseas.
2.23 IMPACT OF GLOBALIZATION ON THE HEALTH SECTOR
2.23.1 There are some apprehensions about the possible adverse impact of economic globalisation on the
health sector. Pharmaceutical drugs and-other health services have always been available in the country at
extremely relatively inexpensive prices, largely due to the effect of the Indian Patent Act of 1970. India has
established a reputation for itself around the globe for innovative development of original process patents for
the manufacture of a wide-range of drugs and vaccines within the ambit of the existing patent laws. With the
adoption of Trade Related Intellectual Property (TRIPS), and the subsequent alignment of domestic patent
laws consistent with the commitments under TRIPS, there will be a significant shift in the scope of the
parameters regulating the manufacture of new drugs/vaccines. Global experience has shown that the
introduction of a TRIPS-consistent patent regime for drugs in a developing country, would result in an
increase in the cost of drugs and medical services and also obstruct research activities in developing countries
like India. NHP-2001 will address itself to the future imperatives of health security in the country, in the postTRIPS era. hshall also engage in a debate to modify me basic contours of the TRIPS agreement.
2.24 NON - HEALTH DETERMINANTS (NOTE: This section should be brought in earlier)
2.24.1 Improved health standards are closely dependent on major non-health determinants such as safe
drinking water supply, basic sanitation, adequate nurr.tion. clean environment and primary education,
especially of the girl child. This is also true for the non communicable diseases like occupational diseases. '
hfe-stvle diseases 1 etc, since safer working enviromem, better transport- policy, a 'health}- policy* about
alcphol and tobacco, — all such interventions are centrally imp, for controllig the no-communicable diseases.
NHP-2001 w-ill not explicitly address itself to all the mmatives-m these areas, which although crucial, fall
outside the domain of the health sector. However, the attainment of the various targets set in NHP 2001
assumes a reasonable performance in these allied sectors. The NHP2001 wil foster an intersectoral approach
to all the developmental issues so that health implicar.ons of development policies would be explicitly’ taken
into account by the concerned planners. For this purpose it also sets out guidelines for developmental
schemes in areas where there is a clear interface between health care and these areas.
2.25 POPULATION GROWTH AND HEALTH STANDARDS
2-25; 1 Efforts made over the years for improving health standards have been neutralized by the rapid growth
of the population. Unless the Population stabilization goals are achieved, no amount of effort in the othcr
eomponents of the public health sector can bring about significantly better national health-standards,
(government has separately announced the 'National Population Policy—2-000'. The-principal common
teaHH-e?. covered under the National Population Policy 2000 and NHP 2001. relate to the prevention and
control of communicable diseases; priority to containment of HlV/AIDS infection: universal immuni/ationW
elnldren aga-mst all major preventable diseases; addressing the unmet needs for basic and reproductive health
services; and supplementation of infrastructure. The synchronized implementation of these two Policies
National Population Policy—2000 and National Health Policy 2001—will be the very comerstone of an\
nat-ional structural plan to improve the health-standards in the country. There is a urowmu global consensus on
the juiihty of running separate programmes aimed at population control; programmes, moreover, that
invariably tend to be target oriented and incorporate vary ing degrees of coercion. The NHP200I has noted
earlier the need to integrate vertical programmes within the decentralised primary health care network. The
NHP2001 suggests means by which this can also be done in the case of programmes aimed al population
stabilisation. The NHP2001 makes these suggestion while keeping in mind the need to make such a
programme_.C-ntirelv free of targets and coercion, and recognising the principle that families and women within
families have the right to determine the number of children they want. The contraceptive policy will not target
women and injectable contaceptives will not be introduced. There will be no coercion in population
stabilisation policies.
2.26 ALTERNATIVE SYSTEMS OF MEDICINE
2.26.1 Alternative Systems of Medicine - Ayurveda. Unani. Sidha and Homoeopathy - provide a significant
supplemental contribution to the health care services in the country,,. The main components of NHP-2001
apply equally to the alternative systems of medicine. However, the policy features specific to the alternative
systems of medicine will be presented as a separate document.
3. OBJECTIVES
3.1 The main objective of NHP-2001 is to achieve an acceptable standard of good health amongst the general
population of the country through universal provision of comprehensive primary health care services. This
would mean a much more concerted attention for fostering an intersectoral approach towards developmenal
programmes so that the basic determinants of health are ensured. The approach about healthcare services
would be to increase access to the decentralized public health system by establishing new infrastructure in
deficient areas, and by upgrading the infrastructure in the existing institutions. Overriding importance would
be given to ensuring a more equitable access to health services across the social and geographical expanse of
the country. Emphasis will be given to increasing the aggregate public health investment through a
substantially increased contribution by the Central Government. It is expected that this initiative will
strengthen the capacity of the public health administration at the State level to render effective service
delivery. -The contribution of the private sector in providing health-services would be much enhanced,
particularly for the population group, which can afford to pay for services. Given the situation today it is
envisaged that the private sector will continue to play a role in provision of curative services, but such a role
will need to be monitored through adequate regulatory mechanisms. Primacy will be given to preventive and
first-line curative initiatives at the primary health level through increased sectoral share of allocation.
Emphasis will be laid on rational use of drugs within the allopathic system. Increased access to tried and
tested systems of traditional medicine will be ensured. Within these broad objectives, NHP-2001 will
endeavour to achieve the time-bound goals mentioned in Box-IV.
Box-IV: Goals to be achieved by 2000-2015
Eradicate Polio and Yaws
Eliminate Leprosy
Eliminate Kala Azar
Eliminate Lymphatic Filariasis
Achieve Zero level growth of HIV/AIDS
Reduce Mortality by 50% on account of TB, Malaria and Other
Vector and Water Borne diseases
Non communicable diseaseas
Reduce Prevalence of Blindness to 0.5%
Reduce IMR to 30/1000 And MMR to 100/Lakh
!
I
r
Improve nutrition and reduce proportion of LBW Babies from
30% to 10%
______ _ _______ ____ ________________
2005
2005
2010
2015
2007
2010
2010
2010
2010
Increase utilisation of public health facilities from current Level of 2010
<20 to >75%
Establish an integrated system of surveillance. National Health
Accounts and Health Statistics.
2005
Increase health expenditure by Government as a % of GDP from
the existing 0.9 % to 2.0% 5.0%
2010
of
2010
Increase share of Central grants to Constitute at least 3f%
total health spending
Increase State Sector Health spending from 5.5% to 10% -7% of
the budget .
Further increase to 15%
2005
2010
J
4. NHP-2001 - POLICY PRESCRIPTIONS
4.1 FINANCIAL RESOURCES
The paucity of public health investment is a stark real:?.. Given the extremely difficult fiscal position of the
State Governments, the Central Government will have to play a key bigger role in augmenting public health
investments. Taking into account the gap in health care facilities under NHP-2001 it is planned to increase
health sector expenditure in the public sector to 6 5 percent of GDP, with 2 percent of GDP being contributed
as-public health investment, by the year 2010. The Su:e Governments would also need to increase the
commitment to the health sector. In the first phase, b> 2005. they would be expected to increase the
commitment of their resources to ? 10 percent of the Budget: and, in the second phase, by 2010. to increase it
to 815 percent of the Budget. With the stepping up of me public health investment, the Central Government's
contribution would rise to 24 35 percent from the existing 15 percent, by 2010. The provisioning of higher
public health investments-will-also be contingent upon the increase in absorptive capacity of the public health
administration so as-to-gainfully utilize the funds.
4.2 EQUITY
4.2.1 To meet the objective of reducing various types of inequities and imbalances - inter-regional; across the
rural - urban divide; and between economic classes - the most cost effective method would be to increase the
sectoral outlay in the primary health sector on a per capita basis. Such outlets give access to a vast number of
individuals, and also facilitate preventive and early stage curative initiative, which are cost effective. In
recognition of this public health principle, NHP-200'i envisages an increased allocation of 55 percent of the
total public health investment for the primary health sector: the secondary and tertiary health sectors being
targetted for 35 percent and 10 percent respectively. NHP-2001 projects that the increased aggregate outlays
for the primary health sector will be utilized for strengthening existing facilities and opening additional public
health service outlets, consistent with the norms for such facilities. At the same time the increased quantum of
total funds availaible will ensure that secondary and ternary services are strengthened too and distributed on a
per capita basis..
4.3 DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
4.3.1 NHP-2001--envisages a key role-fer-the-Central Government in designing national programmes with the
active participation of the State Governments. Also, the Policy ensures the provisioning <»f-fmanciaI resources,
m-addition-to-techmcal support, monitoring and evaluation at the national level by the Centre. However. 1 o
optimize the utilization of the public health infrastructure at the primary level. NHP-2001 envisages the
gradual convergence of all health programmes under a single field administration. All Vertical programmes
for control of major diseases kke-TB, Malaria and-HlV-AIDS-would need to be continued till moderate levels
of-prevalence are reached would be integrated with the decentralised health care delivery system. The
integration of the programmes will bring about a desirable optimisation of outcomes through a convergence of
all public health inputs. The-pehey-also envisages that programme implementation be effected through
autonomous bodies-at State and district-levels. State Health Departments' interventions may be limited to the
overall monitormg-of the ac-hievement-ef programme targets and other technical aspects. The-relative
distancin^of-the-programme-implementation from the State-Health Departments will give the protect team
greater operational-flexibilityT Also, the-presence of State Government officials, social activists, private health
professionals and MLAs/MPs-on-the-management boards-ef-the autonomous bodies will facilitate well
informed decision-making. National health programmes will be integrated within the Primary- Health Care
system with decentralised planning, decision-making and implementation. Focus would be shifted from bio
medical and individual based measures to social and community based measures.
The primary medical care institutions including trained village health workers, sub-centres, and the PHCs
staffed by doctors and the entire range of community health functionaries will be placed under the direct and
administrative control of the relevant level panchayati raj institutions. The overall infrastructure of the primary
health care institutions will be under the control of panchayati raj and gram sabhas and provision of free and
accessible secondary and tertiary care will be under the control of Zila Parishads, to be accessed primarily
through referrals from PHCs. The essential components of primary care would be:
*
level health care based on Village Health Workers selected by the community and supported
by the Gram Sabha' Panchayat, and the Government health services:
*
Pl.itnarY..Health Centres and subcentres with adequate staff and supplies which provides quality
curative services at the primary health centre level itself with good support from linkages:
•
A-Comprehensive structure for Primary Health Care in urban areas based on urban PHCs. health posts
and Community Health Workers:
•
Enhanced content of Pnmary Health Care to include all measures which can be pro\ ided at the PHC
level even,for less common or non-communicable diseases (e.g. epilepsy, hypertension, arthritis, pre
eclampsia, skin diseases) abd integrated relevant epidemiological and preventive measures:
*
Surveillance centres at block level to monitor the local epidemiological situation and tertiary care \\ ith
all speciality services, available in every district.
4.4 THE STATE OF PUBLIC HEALTH INFRASTRUCTURE
4.4.1 As has been highlighted in the earlier part of the Policy, the decentralized Public health service outlets
have become practically dysfunctional over large parts of the country. On account of resource constraint, the
supply of drugs by the State Governments is grossly inadequater-The patients at the decentralized level have
hule use for diagnostic services, which in any case would still require them to purchase therapeutic dnms
pnvately. In a situation in which the patient is not getting any therapeutic drugs, there is little incentive for the
potential beneficiaries to access the primary health care system that exists today^.eek the advice of the
nodical professionals in-the public health system. This results in there being no demand for medical services.
IhlS situation IS further,aggravated because medical professionals, and paramedics often absent themselves
from their place of duty. It is also observed that the functioning of the public health service outlets in the four
Southern States - Kerala. Andhra Pradesh, Tamil Nadu and Karnataka - is relatively better, because some
quantum of drugs is distributed through the primary health system network, and the patients have a slake in
approaching the Public health facilities. In this backdrop, NHP-2001 envisages the kick-starting of the revival
of the Primary Health System by providing some essential drugs under Central Government funding through
the decentralized health system. It is expected that the provisioning of essential drugs at the public health
service centres will create a demand for other professional services from the local population, which, in turn,
will boost the general revival of activities in these service centres. In sum. this initiative under NHP-2001 is
launched in the belief that the creation of a beneficiary interest in the public health system, will ensure a more
effective supervision of the public health personnel, through community monitoring, than has been achieved
through the regular administrative line of control.
4.4.2 Global experience has shown that the quality of public health services, as reflected in the attainment of
improved public health indices, is closely linked to the quantum and quality of investment through public
funding in the primary health sector. Box-V gives statistics which show clearly that the standards of health are
more a function of accurate targeting of expenditure on the decentralised primary sector (as observed in China
and Sri Lanka), than a function of the aggregate health expenditure, provided of course the total quantum is
above a critical level.
Box-V: Public Health Spending in select Countries
Indicator
India
j China
j Sri Lanka
Infant Mortality
Rate/1000
°/oHealth
Expenditure to
GDP
%Public
Expenditure on
Health to Total
Health
Expenditure
44.2
70
5.2
17.3
18.5
31
2.7
24.9
6.6
16
3
%Population
with income of
<$1 day
45.4
j
Tk
1 . .........
| USA
6
5.8
96.9
7
13.7
44.1
Therefore, NHP-2001, while committing additional aggregate financial resources, places strong reliance on
the strengthening of the primary health structure, with which to attain improved public health outcomes on an
equitable basis. Further, it also recognizes the practical need for-levying-reasonable user-charges-for certain
secondary and tertiary public-health care-services, for those who can-afford to pay. Global experience has
shown that levying of user charges, at any level, ultimately leads to the denial of services to the poor, who
need them most, The NHP2001 calls for enactment of suitable legislations for raising of resources to support
public health investment by taxing people at higher income levels, and also be heavily taxing acti\ dies that
have an adverse health impact -- like alcohol, tobacco, pan masala, etc,
4.5 EXTENDING PUBLIC HEALTH SERVICES
4.5.1 NHP 2001 envisages that, in the context of-4he availab&ty-and-spread of allopathie-graduates in their
jHHsdtction; State-Govemments^would-consider-the-need-foi-expaHding the pool of medical practitioners to
tnclude a -cadFe-ol^-l-tcentiates-of medical-practice.-as also practrtioneFS of Indian Systems -of Medicine and
Homoeopathy. Simple services/procedures can be provided by such-pFactitmners even outside their
dtsc4plinesras-paFt-of-the-basic-pnmaFy health-services in under served areas. Also.-NIlP 2001 envisages-that
the-scope of use of paramedical-manpower of allopathic disciplines,-in a prescribed func4tonal area adjunct to
their currenMbnctionsT-would-also-be-examined for meeting simple public-health requirements. These
extended areas of functioning of different-categories of med-ieal-manpower can be permitted, after adequate
trai-mng and subject to the-monitormg of-their performance through professional councils.
4.5.2 NHP-2001 also recognizes the need for States to simplify the recruitment procedures and rules for
contract employment in order to provide-trained medicaTmanpower in under served areas.
4.5.1. The NHP2001 envisages that a comprehensive need based humanpower plan for the health sector will
be formulated that addresses the requirement for creation of a much larger pool of paramedical functionaries
and basic doctors in place of the present trend towards over-production of personnel trained in super
specialities.
4.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS
4.6.1 NHP-2001 lays great emphasis upon the implementation of the decentralised primary health care
programme public health programmes through local self Government institutions. The structure of the
national disease control programmes-w-ill have specific components for implementation through such entities.
The Policy urges all State Governments to consider decentralizing implementation of the programmes to such
Institutions by 2005. In order to achieve this, financial incentives-,-over and above the resources allocated for
disease control programmes-,-will be provided by the Central Government.
4.7 MEDICAL EDUCATION
4.7.1 In order to ameliorate the problems being faced on account of the uneven spread of medical colleges in
various parts of the country, NHP-2001, envisages the setting up of a Medical Grants Commission for funding
new Government Medical Colleges in different under-served parts of the country. Also, the Medical Grants
Commission is envisaged to fund the upgradation of the existing Government Medical Colleges of the
country, so as to ensure an improved standard of medical education in the country. There will be no new
medical colleges till the backlog of training centres for diferent types of paramedics is overcome. No new
medical colleges in the private sector will be allowed4.7.2 To enable fresh graduates to effectively contribute to the providing of primary health services, NHP2001 identifies a significant need to modify the existing curriculum. A need based, skill-oriented syllabus,
with a more significant component of practical training, would make fresh doctors useful immediately after
graduation. Major portions of undergraduate medical education should be imparted in district level medical
care institutions, as necessary complement to training provided in medical colleges. At least an year of rural
posting for undergraduate students would be made mandatory, without which license to practice would not be
issued. Similarly, three years of rural posting after post graduation would be made compulsory.
4.7.3 The policy emphasises the need to expose medical students, through the undergraduate syllabus, to the
emerging concerns for geriatric disorders, as also to the cutting edge disciplines of contemporary medical
research. The policy also envisages that the creation of additional seats for post-graduate courses should
reflect the need for more manpower in the deficient specialities.
4,7.4, No more new colleges would be allowed to be opened in the private sector. Steps would be initiated to
close down medical colleges in the private sector that charge fees above a defined norm, and those that do not
have facilities that shall be laid out as basic necessary standards.
4.8 NEED FOR SPECIALISTS IN ‘PUBLIC HEALTH' AND ‘FAMILY MEDICINE'
4.8.1 In order to alleviate the acute shortage of medical personnel with specialization in ‘public health' and
‘family medicine' disciplines, NHP-2001 envisages a reorientation of the undergraduate medical curriculum
so that these disciplines are adequately emphasised, It also envisages the progressive implementation of
mandatory norms to raise the proportion of postgraduate seats in these discipline in medical training
institutions, to reach a stage wherein 14th of the seats are earmarked for these disciplines. It is envisaged that
in the sanctioning of post-graduate seats in future, it shall be insisted upon that a certain reasonable number of
seats be allocated to 'public health’ and 'family medicine' disciplines. Since, the 'public health' discipline has
an interface with many other developmental sectors, specialization in Public health may be encouraged not
only for medical doctors but also for non-medical graduates from the allied fields of public health engineering,
microbiology and other natural sciences.
4.9 URBAN HEALTH
4.9.1 NHP-2001. envisages the setting up of an organised urban primary health care structure. Since the
physical features of an urban setting are different from those in the rural areas, the policy envisages the
adoption of appropriate population norms for the urban public health infrastructure. The structure conceived
under NHP-2001 is a two-tiered three-tiered, one: the primary centre is seen as the first-tier, covering a
population of 10,000, with a dispensary providing OPD facility and essential drugs to enable access to all the
national health programmes; two: a 30 bedded CHC catering to a population of 100,000; and three: a second
third-tier of the urban health organisation at the level of the Government general Hospital, where reference is
made from the primary centre CHC. The Policy envisages that the funding for the urban primary health
system will be jointly borne by the local self-Govemment institutions and State and Central Governments.
4.9.2 The National Health Policy also envisages the establishment of fully-equipped ‘hub-spoke’ trauma care
networks in large urban agglomerations to reduce accident mortality. This would include training and creation
of dispersed facilities to provide adequate "first aid", as well as equipped secondary and tertiary care centres.
4.10 MENTAL HEALTH
4.10.1 NHP - 2001 envisages a network of decentralised mental health services for ameliorating the more
common categories of disorders. The programme outline for such a disease would envisage diagnosis of
common disorders by general duty medical staff and prescription of common therapeutic drugs. The
NHP2001 envisages promotion of measures towards mental health that promote a shift away from a bio
medical model towards a holistic model of mental health. Community support and community based
management of mental health problems would be promoted. Services for early detection and integrated
management of mental health problems would be integrated with Primary Health Care.
4.10.2 In regard to mental health institutions for in-door treatment of patients, the policy envisages the
upgrading of the physical infrastructure of such institutions at Central Government expense so as to secure the
human rights of this vulnerable segment of society. The policy shall draw up guidelines for minimum
standards that need to be adhered to in mental health institutions, and also enact suitable laws to ensure strict
adherence to these.
4.11 INFORMATION, EDUCATION AND COMMUNICATION
4.11.1 NHP-2001 envisages an IEC policy, which maximizes the dissemination of information to those
population groups, which cannot be effectively approached through the mass media only. The focus would
therefore, be on inter-personal communication of information and reliance on folk and other traditional media.
The IEC programme would set specific targets for the association of PRIs/NGOs/Trusts in such activities. The
programme will also have the component of an annual evaluation of the performance of the nonGovemmental agencies to monitor the impact of the programmes on the targeted groups. The Central. State
Government initiative will also focus on the development of modules for information dissemination in such
population groups who normally, do not benefit from the more common media forms.
4.11.2. NHP-2001 envisages priority to school health programmes aiming at preventive health education,
regular health check-ups and promotion of health seeking behaviour among children. The school health
programmes can gainfully adopt specially designed modules in order to disseminate information relating to
‘health’ and ‘family life'. This is expected to be the most cost-effective intervention as it improves the level of
awareness, not only of the extended family, but the future generation as well.
4.12 MEDICAL HEALTH RESEARCH
4.12.1 NHP-2001 envisages the increase in Government-funded medical research to a level of 4 2.5 percent of
total health spending by 2005; and thereafter, up to 2 5 percent by 2010. Domestic medical research would be
focused on new therapeutic drugs and vacoineS'for tropical diseases; such as TB and Malaria, as also the Sub
types of IIIV/AIDS-prevalenHn-the country. Research programmes taken up by the Government in these
priority areas-would be conducted-in a mission mode. Emphasis-would also be paid to time bound applied
research-for developing operational applications. This-would ensure cost-effective dissemination of existing ■
future therapeutic drugs/vaccines in the general population. Private entrepreneurship will be encouraged in the
field-ofmedical research for new' molecules-/-vaccines. NHP 2001 envisages focusing of Health Research in
the country, first, on optimisation of public health strategies, and also on therapeutic drugs/vaccines
development for tropical diseases, which are normally neglected by international pharmaceutical companies
on account of limited profitability potential. Research actinties will also need to focus on the newly-emerging
frontier areas of research based on genetics, genome-based drug and vaccine development, molecular biology,
etc.
4.13 ROLE OF THE PRIVATE SECTOR
4.13.1 NHP2001 will initiate measures to ensure that the unbridled and unchecked growth of the commercial
private sector is brought to a halt. Strict observance of standard guidelines for medical and surgical
intervention and use of diagnostics, standard fee structure, and periodic prescription audit shall be made
obligator}'. Legal and social mechanisms will be set up to ensure observance of minimum standards by all
private hospitals, nursing/matemity homes and medical laboratories. The prevalent practice of offering
commissions for referral will be made punishable by law. For this purpose a body with statutory powers will
be constituted, which has due representation from peoples organisations and professional organisations. NHP2001' envisages the enactment of suitable legislations for-regulating minimum infrastructure and quality
standards by 2003. in clinical establishments/medica- msti-tuhons; also, statutory guidelines for the conduct of
clinical practice and-delivery of medical'services are to be developed over the same period. The policy also
encourages the setting up of-private insurance instruments-for increasing-the scope of the coverage of the
secondary-and tertiary-sector-under private health insurance-packages;
4.13.2 To capitalize on the comparative cost advantage enjoyed by domestic health facilities in the secondary
and tertiary sector, the policy will encourage the supply of services to patients of foreign origin on payment.
The rendering of such services on payment in foreign exchange will be treated as ‘deemed exports' and will
be made eligible for all fiscal incentives extended to export earnings. However such facilities will be extended
only in cases where not more than 10% of the facilities of any institution are put to such use.
4.13.3 NHP-2001 envisages the co-option of the non-governmental practitioners m the national disease
control programmes so as to ensure that standard treatment protocols are followed in their day-to-day practice.
4.13;4-NHP 2001 recognizes the 4mmense potential of use of information technology applications in the area
of tele medicine m-the tertiary health care sector-.' The use of this technical aid will greatly enhance the
capacity for the professionals to pool their clinical experience.
4.14 ROLE OF THE CIVIL SOCIETY
4.14.1 NHP-2001 recognizes the significant contribution made by NGOs and other institutions of the civil
society in monitoring public health programmes and m ensuring community mobilisation and participation as
regards public health programmes, making available health-services to lhe-communiiy. NHP2001 envisages
the utilisation of NGOs and civil society organisations in the monitoring of public health programmes and in
increasing participation of local communities in planning and implementation of such programmes. They
would also have a major role in community mobilisation, and in building the capacities of Panchayati Raj
Institutions. In order -to utilize on an increasing-scale, their high "mot Fvattonal skills. NHP-2001 envisages that
the disease control ■programmes-sheuld-earmark-a-defin-ite portion-e-fehe budget in respect of-tdenlified
programme components. lo-be-excfesi-vely-impfemented-threHgh-these-mstitutions.
4.15 NATIONAL DISEASE SURVEILLANCE NETWORK
4.15J NHP-2001 envisages the full operationalization of an integrated disease control network from the
lowest rung of public health administration to the Central Government, by 2005. The programme for setting
up this network will include components relating to installation of data-base handling hardware: IT inter
connectivity between different tiers of the network; and. in-house training for data collection and
interpretation for undertaking timely and effective response.
4.16 HEALTH STATISTICS
4.16.1 NHP-2001 envisages the completion of baseline estimates for the incidence of the common diseases TB. Malaria. Blindness - by 2005. The Policy proposes that statistical methods be put in place to enable the
periodic updating of these baseline estimates through representative sampling, under an appropriate statistical
methodology. The policy also recognizes the need to establish in a longer time frame, baseline estimates for :
the non-communicable diseases, like CVD, Cancer, Diabetes; accidental injuries; and other communicable
diseases, like Hepatitis and IE. NHP-2001 envisages that, with access to such reliable data on the incidence of
various diseases, the public health system would move closer to the objective of evidence-based policy
making.
4.16.2 In an attempt at consolidating the data base and graduating from a mere estimation of annual health
expenditure, NHP-2001 emphasis on the needs to establish national health accounts, conforming to the
'source-to-users’ matrix structure. Improved and comprehensive information through national health accounts
and accounting systems would pave the way for decision makers to focus on relative priorities, keeping in
view the limited financial resources in the health sector.
4.17 WOMEN’S HEALTH
4.17.1 NHP-2001 envisages the identification of specific programmes targeted at women's health. The policy
notes that women, along with other under privileged groups are significantly handicapped due to a
disproportionately low access to health care. The various Policy recommendations of NHP-2001. in regard to
the expansion of primary health sector infrastructure, will facilitate the increased access of women to basic
health care. NHP-2001 commits the highest priority of the Central Government to the funding of the identified
programmes relating to woman’s health. Also, the policy recognizes the need to review the staffing norms of
the public health administration to more comprehensively meet the specific requirements of women.
4,17.2. NHP2001 will set in operation Women-centered health initiatives that include:
• awareness generation for social change on issues of gender and health, triple work burden, gender
discrimination in nutrition and health-care:
• preventive and curative measures to deal with health consequences of womens’ work and domestic
violence;
• complete maternity benefits and child care facilities to be provided in all occupations employing
women, be they in the organized or unorganized sector;
• special support structures that focus on single, deserted, widowed women and commercial sex
workers; gender sensitive services to deal with reproductive health including reproductive system
illnesses, maternal health, abortion, and inferrility;
• vigorous public campaign accompanied by legal and administrative action against female feticide,
infanticide and sex pre-selection.
POPULATION POLICY
All coercive measures including incentives and disincentives for limiting family size would be abolished. The
right of families and women within families in determining the number of children they want should be
recognised. Concurrently, access to safe and affordable contraceptive measures would be ensured which
provides people, especially women, the ability to make an informed choice. All long-term, invasive, systemic
hazardous contraceptive technologies such as the injectables (NET-EN, Dcpo-Provcra, etc.), sub-dermal
implants (Norplant) and anti fertility vaccines would be banned from both the public and private sector,
Urgent measure would be initiated to shift to onus of contraception away from w omen and ensure at least
equal emphasis on men’s responsibility for contraception.
CHILD HEALTH
The NHP2001 shall put in operation Child centered health initiatives which include:
• a comprehensive child rights code, adequate budgetary allocation for universalisation of child care
services, a expanded and revitalized ICDS programme and ensuring adequate support to working
women to facilitate child care, especially breast feeding;
• a emprehensive supplementary feeding programme and nutrition awareness programme that addresses
the needs of all umdemourished children below the age of 5;
• comprehensive measures to prevent child abuse and sexual abuse;
• educational, economic and legal measures to eradicate child labour, accompanied by measures to ensure
free and compulsory elementary education for all children.
4.18 MEDICAL ETHICS
4.18.1 NHP 2001 envisages that, in order to ensurethat the common patient is not subjected to irrational or
profit-driven medical regimens, a contemporary code of ethics be notified and rigorously implemented by the
Medical Council of India.
■1.18.2 NHP—20(M-does not offer any policy prescription at this-stage-relating- to ethics-in the conduct of
medical research. By and large medical-research-within the country- is limited m-these-frontier discipline^ of
gene manipulation-and stem cell research-.-However, the policy recognises that-a-vrgil-aHt watch will have to be
kept so that appropriate guidelines and statutory provisions are put-in-place when medical-research tn the
country reaches the stage to make such-issues relevant.
4.18.2. Ethical guidelines for research involving human subjects shall be drawn up and implemented after an
open public debate. No further experimentation, involving human subjects, will be allowed without a proper
and legally tenable informed consent and appropriate legal protection. Failure to do so to be punishable by
law. All unetical research, especially in the area of contraceptive reseach, would be stopped forthwith. Women
(and men) who, without their consent and knowledge, have been subjected to experimentation, especially with
hazardous contraceptive technologies will be traced forthwith and appropriately compensated. Exemplary
damages shall be awarded against the institutions (public and private sector) involved in such anti-people,
unethical and illegal practices in the past.
ENSURING ACCESS TO ESSENTIAL DRUGS, AND RATIONAL DRI G USE
The NHP2001 envisages the formulation of a rational drug policy, under the aegis of the Ministry of Health,
that ensures development and growth of a self reliant industry for production of all essential drugs at
affordable prices and of proper quality. The policy should, on a priority basis:
• ban all irrational and hazardous drugs;
• introduce production quotas and price ceiling for essential drugs;
• promote compulsory use of generic names;
• regulate advertisements, promotion and marketing of all medications based on ethical criteria;
• formulate guidelines for use of old and new vaccines:
• control the activities of the multinational sector and restrict their presence only to areas where they are
willing to bring in new technology;
• recommend repeal of the new patent act and bring back mechanisms that prevent creation of
monopolies and promote introduction of new drugs at affordable prices;
• promotion of the public sector in production of drugs and medical supplies, moving towards complete
self-reliance in these areas.
4.19 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DRUGS
4.19.1 NHP - 2001 envisages that the food and drug administration will be progressively strengthened, both in
terms of laboratory facilities and technical expertise. Also, the policy envisages that the standards of food
items will be progressively tightened at a pace which will permit domestic food handling / manufacturing
facilities to undertake the necessary upgradation of technology so as not to be shut out of this production
sector. The policy envisages that, ultimately food standards will be close, if not equivalent, to codex
specifications; and drug standards-will be-at par with the most rigorous ones adopted elsewhere.
4.20 REGULATION OF STANDARDS IN PARAMEDICAL DISCIPLINES
4.20.1 NHP-2001 recognises the need for the establishment of statutory professional councils for paramedical
disciplines to register practitioners, maintain standards of training, as well as to monitor their performance.
4.21 OCCUPATIONAL HEALTH
4.21.1 NHP-2001 envisages the periodic screening of the health conditions of the workers, particularly for
high risk health disorders associated with their occupation.
4.21.2. NHP200L further, envisages special measures relating to occupational and environmental health
which will focus on:
• banning of hazardous technologies in industry and agriculture;
• worker centered monitoring of working conditions with the onus of ensuring a safe w orkplace on the
management;
• reonentation of medical services for early detection of occupational disease;
• special measures to reduce the likelihood of accidents and injuries in different settings, such as traffic
accidents, industrial accidents, agricultural injuries, etc.
1.22 PROVIDING MEDICAL FACILITIES TO USERS-FROM OVERSEAS
4-.22.1-NHP 2001 strongly enceurages the providing of health services-on a commercial basis to service
seekers from overseas. The providers of such services to patients from overseas will be encouraged by
extending to their earnings in-foreign exchange, all fiscal incentives available to other exporters of-goods and
services.
4.23 IMPACT OF GLOBALISATION ON THE HEALTH SECTOR
4.23.1 NHP-2001 takes into account the serious apprehension expressed by several health experts, of the
possible threat to the health security, in the post TRIPS era, as a result of a sharp increase in the prices of
drugs and vaccines and constraints on medical research- To protect the citizens of the country from such a
threat. NHP-2001 envisages a national patent regime for the future which, while being consistent with TRIPS,
avails of all opportunities to secure for the country, under its patent laws, affordable access to the latest
medical and other therapeutic discoveries. The Policy also sets out that the Government will bring to bear its
full influence in all international fora - UN, WHO, WTO, etc. - to secure commitments on the part of the
Nations of the Globe, to lighten the restrictive features of TRIPS in its application to the health care sector.
RESTRICTION ON HAZARDOUS PRACTICES/INDUSTRIES
NNP2001 envisages effective restriction on industries that promote addictions and an unhealthy lifestyle, like
limil
tobacco, alcohol, pan masala etc,, starting with an immediate
ban on advertising and sale of their products to
the young, and provision of services for de-addiction,
PROMOTION OF HEALTH AMONG PHYSICALLY & MENTALLY CHALLENGED
NHP2001 envisages measures to promote the health of physically and mentally disadvantaged by focussing
on the abilities rather than deficiencies. Focus would be on promotion of measures to integrate them in the
community with special support rather than segregating them; ensuring equitable opportunities for education,
employment and special health care including rehabilitative measures,
5. SUMMATION
5.1 The crafting of a National-Healt-h-Policy is a rare occasion in public affairs-when-it-would be legitimate.
indeed valuable, to-allow our dreams to mingle with our understanding of ground realities. Based-purely on
the-chmcal facts defining the-current status-of the health sector-we-would have arrived at-a-eertam policy
formulatiom-butrbuoyed by our-dreamsy we have ventured-shghtly beyond that in the shape of-NHP 2001
which, in fact, defmes-a-vision for the-foture.
5.2 The health needs of the country are enormous and the financial resources and managerial capacityavailable to meet it, even on the most optimistic projections, fall somewhat short. In this situation. XHP-2001
has had to make hard choices between various priorities and operational options. NHP-2001 does not claim to
be a road-map for meeting all the health needs of the populace of the country. Further, it has to be recognized
that such health needs are also dynamic as threats in the area of public health keep changing over time. The
Policy, while being holistic, undertakes the necessary- risk of recommending differing emphasis on different
policy components. Broadly speaking, NHP - 2001 focuses on the need for enhanced funding and an
organizational restructuring of the national public health initiatives in order to facilitate more equitable access
to the health facilities. Also, the policy is focused on those diseases which are principally contributing to the
disease burden - TB, Malaria and Blindness from the category of historical diseases; and HIV/AIDS from the
category' of ‘newly emerging diseases’. This is not to say that other items contributing to the disease burden of
the country will be ignored; but only that, resources as also the principal focus of the public health
administration, will recognize certain relative priorities.
5.3 One nagging imperative, which has influenced every- aspect of NHP-2001. is the need to ensure that
“equity' in the health sector stands as an independent goal. In any future evaluation of its success or failure.
NHP-2001 would like to be measured against this equity norm, rather than any other aggregated financial
norm for the health sector. Consistent with the primacy given to ‘equity’, a marked emphasis has been
provided in the policy for expanding and improving the primary health facilities, including the new concept of
provisioning of essential drugs through Central funding. The Policy also commits the Central Government to
increased under-writing of the resources for meeting the minimum health needs of the citizenry. Thus, the
Policy attempts to provide guidance for prioritizing expenditure, thereby, facilitating rational resource
allocation.
5.4 NHP-2001 highlights the expected roles of different participating group in the health sector. Further, it
recognizes the fact that, despite all that may be guaranteed by the Central Government for assisting public
health programmes, public health services would actually need to be delivered by the State administration;
NGOs and-otheninstitutions of-eivil society. The attainment of improved health indices would be significantly
dependent on population-stabilisation; as also on complementary efforts from other areas of the social sectors
- like improved drinking water supply, basic sanitation, minimum nutrition, etc. - to ensure that the exposure
of the populace to health risks is minimized.
ANNEXUREI
PEOPLE’S HEALTH CHARTER
We the people of India, stand united in our condemmtion of an iniquitous global system that, under the garb
of “globalisation” seeks to heap unprecedented misery and destitution on the overwhelming majority of the
people on this globe. This system has systematically ravaged the economies of poor nations in order to extract
profits that nurture a handful of powerful nations and corporations. The poor, across the globe, are being
further marginalised as they are displaced from home and hearth and alienated from their sources of livelihood
as a result of the forces unleashed by this system. Standing in firm opposition to such a system we reaffirm
our inalienable right to comprehensive health care that includes food security: sustainable livelihood options:
access to housing, drinking water and sanitation; and appropriate medical care for all; in sum — the right to
HEALTH FOR ALL, NOW!
The promises made to us by the international community in the Alma Ata declaration have been
systematically repudiated by the World Bank, the IMF, the WTO and its predecessors, the World Health
Organization, and by a government that functions under the dictates of international Finance Capital. The
forces of “globalization” through measures such as the structural adjustment programme are targeting our
resources — built up with our labour, sweat and lives over the last fifty years — and placing them in the
service of the global “market” for extraction of super-profits. The benefits of the public sector health care
institutions, the public distribution system and other infrastructure - such as they were - have been taken
away from us. It is the ultimate irony that we are now blamed for our plight, with the argument that it is our
numbers and our propensity to multiply that is responsible for our poverty and deprivation.
We declare health as a justiciable right and demand the provision of basic health care as a fundamental
constitutional right of every one of us. We assert our right to take control of our health in our own hands and
for this the right to:
• A truly decentralised system of local governance vested with adequate power and responsibilities and
provided with adequate finances;
• A sustainable system of agriculture based on the principle of “land to the tiller”, linked to a decentralized
public distribution system that ensures that no one goes hungry;
• Universal access to education, adequate and safe drinking water, and housing and sanitation facilities:
• A dignified and sustainable livelihood;
• A clean and sustainable environment;
• A drug industry geared to producing epidemiologically essential drugs at affordable cost:
• A health care system which is responsive to the people’s needs and whose control is vested in peoples
hands:
Further, we declare our firm opposition to:
• Agricultural policies attuned to the needs of the “market” that ignore disaggregated and equitable access to
food
• Destruction of our means to livelihood and appropriation, for private profit, of our natural resource bases:
• The conversion of Health to the mere provision of medical facilities and care that are technology intensive,
expensive, and accessible to a select few;
• The retreat, by the government, from the principle of providing free medical care, through reduction of
public sector expenditure on medical care and introduction of user fees in public sector medical
institutions, that place an unacceptable burden on the poor;
• The corporatization of medical care, state subsidies to the corporate sector in medical care, and corporate
sector health insurance;
• Coercive population control and promotion of hazardous contraceptive technology;
• The use of patent regimes to steal our traditional knowledge and to put medical technology and drugs
beyond our reach;
• Institutionalization of divisive and oppressive forces in society, such as fundamentalism, caste, patriarchy,
and the attendant violence, which have destroyed our peace and fragmented our solidarity.
In the light of the above we demand that:
1. The concept of comprehensive primary health care, as envisioned in the Alma Ata Declaration should form
the fundamental basis for formulation of all policies related to health care. The trend towards
fragmentation of health delivery programmes through conduct of a number of vertical programmes should
be reversed. National health programmes be integrated within the Primary Health Care system with
decentralized planning, decision-making and implementation. Focus be shifted from bio-medical and
individual based measures to social, ecological and community based measures.
2. The primary medical care institutions including trained village health workers, sub-centres, and the PHCs
staffed by doctors and the entire range of community health functionaries be placed under the direct
administrative and financial control of the relevant level panchayat raj institutions. The overall
infrastructure of the primary health care institutions be under the control of panchayati raj and gram sabhas
and provision of free and accessible secondary and tertiary level care be under the control of Zilla
Panshads, to be accessed primarily through referrals from PHCs. The essential components of primary care
should be:
• Village level health care based on Village Health Workers selected by the community and supported by
the Gram Sabha / Panchayat and the Government health services:
• Primary Health Centers and subcentres with adequate staff and supplies which provides quality curative
services at the primary health center level itself with good support from linkages;
• A comprehensive structure for Primary Health Care in urban areas based on urban PHCs. health posts
and Community Health Workers;
• Enhanced content of Primary Health Care to include all measures which can be provided at the PHC
level even for less common or non-communicable diseases (e.g. epilepsy, hypertension, arthritis, pre
eclampsia, skin diseases) and integrated relevant epidemiological and preventive measures.
• Surveillance centres at block level to monitor the local epedemiological situation and tertiary care with
all speciality services, availaible in every district.
3. A comprehensive medical care programme financed by the government to the extent of at least 5% of our
GNP. of which at least half be disbursed to panchayati raj institutions to finance primary level care. This be
accompanied by transfer of responsibilities to PRIs to run major parts of such a programme, along with
measures to enhance capacities of PRIs to undertake the tasks involved.
4. The policy of gradual privatisation of government medical institutions, through mechanisms such as
introduction of user fees even for the poor, allowing private practice by Government Doctors, giving out
PHCs on contract, etc. be abandoned forthwith. Failure to provide appropriate medical care to a citizen by
public health care institutions be made punishable by law.
5. A comprehensive need-based humanpower plan for the health sector be formulated that addresses the
requirement for creation of a much larger pool of paramedical functionaries and basic doctors, in place of
the present trend towards over-production of personnel trained in super-specialities. Major portions of
undergraduate medical education, nursing as well as other paramedical training be imparted in district level
medical care institutions, as a necessary complement to training provided in medical/nursing colleges and
other training institutions. No more new medical colleges to be opened in the private sector. Steps be taken
forthwith to close down private medical colleges charging fees higher than state colleges or taking any
form of donations, and to eliminate illegal private tuition by teachers in medical colleges. At least an year
of compulsory rural posting for undergraduate (medical, nursing and paramedical) education be made
mandatory, without which license to practice not be issued. Similarly, three years of rural posting after
post graduation be made compulsory.
6. The unbridled and unchecked growth of the commercial private sector be brought to a halt. Strict
observance of standard guidelines for medical and surgical intervention and use of diagnostics, standard
fee structure, and periodic prescription audit to be made obligatory'. Legal and social mechanisms be set up
to ensure observance of minimum standards by all private hospitals, nursing/matemity homes and medical
laboratories. Prevalent practice of offering commissions for referral to be made punishable by law. For this
purpose a body with statutory powers be constituted, which has due representation from peoples
organisations and professional organisations.
7. A rational drug policy be formulated that ensures development and growth of a self reliant industry for
production of all essential drugs at affordable prices and of proper quality. The policy should, on a priority
basis:
• ban all irrational and hazardous drugs;
• introduce production quotas and price ceiling for essential drugs;
• promote compulsory use of generic names;
• regulate advertisements, promotion and marketing of all medications based on ethical criteria;
• formulate guidelines for use of old and new vaccines;
• control the activities of the multinational sector and restrict their presence only to areas where they are
willing to bring in new technology;
• recommend repeal of the new patent act and bring back mechanisms that prevent creation of
monopolies and promote introduction of new drugs at affordable prices;
• promotion of the public sector in production of drugs and medical supplies, moving towards complete
self-reliance in these areas.
8. Medical Reseach priorities be based on morbidity and mortality profile of the country , and details regarding
the direction, intent and focus of all research programmes be made entirely transparent. Adequate
government funding be provided for such programmes. Ethical guidelines for research involving human
subjects be drawn up and implemented after an open public debate. No further experimentation, involving
human subjects, be allowed without a proper and legally tenable informed consent and appropriate legal
protection. Failure to do so to be punishable by law. All unetical research, especially in the area of
contraceptive reseach, be stopped forthwith. Women (and men) who. without their consent and knowledge,
have been subjected to experimentation, especially with hazardous contraceptive technologies to be traced
forthwith and appropriately compensated. Exemplary damages to be awarded against the institutions
(public and private sector) involved in such anti-people, unethical and illegal practices in the past.
9. All coercive measures including incentives and disincentives for limiting family size be abolished. The
right of families and women within families in determining the number of children they want should be
recognised. Concurrently, access to safe and affordable contraceptive measures be ensured which provides
people, especially women, the ability to make an informed choice. All long-term, invasive, systemic
hazardous contraceptive technologies such as the injectables (NET-EN, Depo-Provera. etc.), sub-dermal
implants (Norplant) and anti fertility vaccines should be banned from both the public and private sector.
Urgent measure be initiated to shift to onus of contraception away from women and ensure at least equal
emphasis on men's responsibility for contraception.
10.Support be provided to traditional healing systems, including local and home-based healing traditions, for
systematic research and community based evaluation with a view to developing the knowledge base and
use of these systems along with modem medicine as part of a holistic healing perspective.
11. Promotion of transparency and decentralisation in the decision making process, related to health care, at
all levels as well as adherence to the principle of right to information. Changes in health policies to be
made only after mandatory wider scientific public debate.
12.Introduction of ecological and social measures to check resurgence of communicable diseases.
measures should include:
Such
• integration of health impact assessment into all development projects;
• decentralized and effective surveillance and compulsory notification of prevalent diseases like malaria.
TB by all health care providers, including private practitioners;
• reorientation of measures to check STDs/AIDS through universal sex education, checking social
disruption and displacement and commercialisation of sex. generating public awareness to remove
stigma and universal availability of preventive and curative services, and special attention to
empowering women and availability of gender sensitive services in this regard.
□ .Facilities for early detection and treatment of non-communicable diseaseslike diabetes,
diseases, etc. to be available to all att appropriate levels of medical care.
cancers, bean
14. Women-centered health initiatives that include:
• awareness generation for social change on issues of gender and health, triple work burden, gender
discrimination in nutrition and health-care;
• preventive and curative measures to deal with health consequences of womens' work and domestic
violence;
• complete maternity benefits and child care facilities to be provided in all occupations employing
women, be they in the organized or unorganized sector;
• special support structures that focus on single, deserted, widowed women and commercial sex workers;
gender sensitive sendees to deal with reproductive health including reproductive system illnesses,
maternal health, abortion, and infertility;
• vigorous public campaign accompanied by legal and administrative action against female feticide,
infanticide and sex pre-selection.
15.Child centered health initiatives which include:
• a comprehensive child rights code, adequate budgetary allocation for universalisation of child care
services, a expanded and revitalized ICDS programme and ensuring adequate support to working
women to facilitate child care, especially breast feeding;
• comprehensive measures to prevent child abuse and sexual abuse;
• educational, economic and legal measures to eradicate child labour, accompanied by measures to ensure
free and compulsory elementary education for all children.
16.Special measures relating to occupational and environmental health which focus on:
• banning of hazardous technologies in industry and agriculture;
• worker centered monitoring of working conditions with the onus of ensuring a safe workplace on the
management;
• reorientation of medical services for early detection of occupational disease;
• special measures to reduce the likelihood of accidents and injuries in different settings, such as traffic
accidents, industrial accidents, agricultural injuries, etc.
17.Measures towards mental health that promote a shift away from a bio-medical model towards a holistic
model of mental health. Community support and community based management of mental health problems
be promoted. Services for early detection and integrated management of mental health problems be
integrated with Primary Health Care.
18.Measures to promote the health of the elderly by ensuring economic security, opportunities for appropriate
employment, sensitive health care facilities and, when necessary, shelter for the elderly.
19. Measures to promote the health of physically and mentally disadvantaged by focussing on the abilities
rather than deficiencies. Promotion of measures to integrate them in the community with special support
rather than segregating them; ensuring equitable opportunities for education, employment and special
health care including rehabilitative measures.
20.Effective restriction on industries that promote addictions and an unhealthy lifestyle, like tobacco, alcohol,
pan masala etc., starting with an immediate ban on advertising and sale of their products to the young, and
provision of services for de-addiction.
ANNEXLRE II
National Health Policy-2001
A comparison with the People’s Health Charter
Sr.
1.
2.
People’s Health Charter
Introduction- We, the people of India
affirm our inalienable right to and demand
for comprehensive health care that includes
food secunty; sustainable livelihood options
including secure employment opportunities;
access to housing, drinking water and
sanitation; and appropriate medical care for
all; in sum - the right to Health For All,
Now!
The concept of comprehensive primary
health care, as envisioned in the Alma Ata
Declaration should form the fundamental
basis for formulation of all policies related to
health care. The trend towards fragmentation
of health delivery programmes through
conduct of a number of vertical programmes
should be reversed. National health
programmes be integrated within the
Primary
Health Care
system
with
decentralized planning, decision-making and
implementation with the active participation
of the community. Focus be shifted from
bio-medical and individual based measures
to social, ecological and community based
measures.
The primary health care institutions
including trained village health workers,
sub-centers, and the PHCs staffed by doctors
and the entire range of community health
functionaries including the ICDS workers,
be placed under the direct administrative and
NHP- 2001
The Health Policy does not state at the outset, what is
essential for good health, and wherefor we are headed by
way of this policy.
■
Alma Ata Declaration not mentioned
4.3 DELIVERY OF NATIONAL PVBLK HEALTH
PROGRAMMES
4.3.1 NHP-2001, envisages a key role for the Central
Government m designing national programmes with the
act’ve participation of the State Governments. Also, the
Policy ensures the provisioning of financial resources, in
addition to technical support, monitoring and evaluation at
the national level by the Centre. However, to optimize the
utilization of the public health infrastructure at the primary
leveh NHP-2001 envisages the gradual convergence of all
health programmes under a single field administration,
Vertical programmes for control of major diseases like TB.
Malaria and HIV/AIDS would need to be continued till
moderate levels of prevalence are reached. The integration
of the programmes will bring about a desirable
optimisation of outcomes through a convergence of all
public health inputs. The policy also envisages that
programme implementation be effected through
autonomous bodies at State and district levels. State Health
Departments’ interventions may be limited to the overall
monitoring of the achievement of programme targets and
other technical aspects. The relative distancing of the
programme implementation from the State Health
| Departments will give the project team greater operational
: flexibility. Also, the presence of State Government
officials, social activists, private health professionals and
MLAs/MPs on the management boards of the autonomous
bodies will facilitate well-informed decision-making.
4.6 ROLE OF LOCAL SELF-CrOV ERNMENl
INSTITUTIONS
4.6.1 NHP-2001 lays great emphasis upon the
implementation of public health programmes through local
self Government institutions. The structure of the national
financial control of the relevant level disease control programmes will have specific components
Panchayati Raj institutions. The overall for implementation through such entities. The Policy urges
infrastructure of the primary health care all State Governments to consider decentralizing
institutions be under the control of implementation of the programmes to such Institutions by
Panchayats and Gram Sabhas and provision 2005. In order to achieve this, financial incentives, over
of free and accessible secondary and tertiary and above the resources allocated for disease control
level care be under the control of Zilla programmes, will be provided by the Central Government.
Parishads. to be accessed primarily through ■
referrals from PHCs.
3.
The essential components of primary ■
care should be:
■ Village level health care based on i
Village Health Workers selected by the
community and supported by the Gram
Sabha / Panchayat and the Government
health services which are given
regulatory powers and adequate resource
support
Primary health care approach not mentioned at all.
■
Primary Health Centers and sub-centers 4.4 THE STATE OF PLBLIC HEAI/FH
with adequate staff and supplies which INFRASTRLCTl RE
proxides quality curative services at the
primary health center level itself with 4.4.1 NHP-2001 envisages the kick-starting of the revival
good support from referral linkages
of the Primary Health System by providing some essential
drugs under Central Government funding through the
decentralized health system. It is expected that the
provisioning of essential drugs at the public health service
centres will create a demand for other professional services
from the local population, which, in turn, will boost the
general revival of activities in these service centres. In
sum, this initiative under NHP-2001 is launched in the
belief that the creation of a beneficiary interest in the
public health system, will ensure a more effective
supervision of the public health personnel, through
community monitoring, than has been achieved through the
regular administrative line of control.
■
A comprehensive structure for Primary 4.9 I RBAN HEALTH
Health Care in urban areas based on
urban
PHCs. health posts and 4.9.1 NHP-2001, envisages the setting up of an organised
Community Health Workers under the urban primary health care structure. Since the physical
control of local self government such as features of an urban setting are different from those in the
ward committees and municipalities.
rural areas, the policy envisages the adoption of
appropriate population norms for the urban public health
infrastructure. The structure conceived under NHP-2001 is
a two-tiered one: the primary centre is seen as the first-tier,
covering a population of one lakh, with a dispensary
providing OPD facility and essential drugs to enable access
to all the national health programmes: and a second-tier of
the urban health organisation at the level of the
Government general Hospital, where reference is made
from the primary centre. The Policy envisages that the
funding for the urban primary health system will be jointly
borne by the local self-Govemment institutions and State
and Central Governments.
4.9.2 The National Health Policy also envisages the
establishment of fully-equipped ‘hub-spoke’ trauma care
networks in large urban agglomerations to reduce accident
mortality.
■
Enhanced content of Primary Health j
Care to include all measures which can
be provided at the PHC level even for
less common or non-communicable
diseases (e.g. epilepsy, hypertension,
arthritis, pre-eclampsia, skin diseases)
and integrated relevant epidemiological
and preventive measures
Surveillance centers at block level to
monitor the local epidemiological
situation and tertiary care 1with all
speciality services, available in every
district.
4.
A comprehensive medical care programme
financed by the government to the extent of
at least 5% of our GNP, of which at least
half be disbursed to panchayati raJ
institutions to finance primary level care.
This be <accompanied by transfer of
responsibilities to PRIs to run major parts of
such a programme, along with measures to
enhance capacities of PRJs to undertake the
tasks involved.
4.15 NATIONAL DISEASE SURVEILLANCE
NETWORK
4.15.1 NHP-2001 envisages the full operationalization of
an integrated disease control network from the lowest rung
of public health administration to the Central Government,
by 2005. The programme for setting up this network will
include components relating to installation of data-base
handling hardware; IT inter-connectivity between different
tiers of the network; and, in-house training for data
collection and interpretation for undertaking timely and
effective response.
4.1 FINANCIAL RESOURCES
The paucity of public health investment is a stark reality.
Given the extremely difficult fiscal position of the State
Governments, the Central Government will have to play a
ro]e jn augmenting public health investments. Taking
into account the gap in health care facilities under NHP2001 it is planned to increase health sector expenditure to 6
percent of GDP, with 2 percent of GDP being contributed
as public health investment, by the year 2010. The State
Governments would also need to increase the commitment
to the health sector. In the first phase, by 2005, they would
be expected to increase the commitment of their resources
to 7 percent of the Budget; and, in the second phase, by
2010, to increase it to 8 percent of the Budget. With the
stepping up of the public health investment, the Central
Government’s contribution would rise to 25 percent from
the existing 15 percent, by 2010. The provisioning of
higher public health investments will also be contingent
upon the increase in absorptive capacity of the public
health administration so as to gainfully utilize the funds.
4.2 EQUITY
4.2.1 To meet the objective of reducing various types of
inequities and imbalances - inter-regional; across the rural
- urban divide; and between economic classes - the most
cost effective method would be to increase the sectoral
outlay in the primary health sector. Such outlets give
access to a vast number of individuals, and also facilitate
preventive and early stage curative initiative, which are
cost effective. In recognition of this public health principle.
NHP-2001 envisages an increased allocation ot 55 percent
of the total public health investment for the primary health
sector; the secondary and tertiary health sectors being
targetted for 35 percent and 10 percent respectively. NHP2001 projects that the increased aggregate outlays for the
primary health sector will be utilized for strengthening
existing facilities and opening additional public health
service outlets, consistent with the norms for such
facilities.
5.
The policy of gradual privatisationj of
government medical institutions, through
mechanisms such as introduction of user fees
even for the poor, allowing private practice
by Government Doctors, giving out PHCs on
contract, etc. be abandoned forthwith.
Failure to provide appropriate medical care
to a citizen by public health care institutions
be made punishable by law.
6.
A comprehensive need-based human-power ' 4.5 EXTENDING PUBLIC HEALTH SERYIOIS
plan for the health sector be formulated that
addresses the requirement for creation of a 4.5.1 NHP-2001 envisages that, in the context of the
much
larger
pool
of paramedical availability and spread of allopathic graduates in their
functionaries and basic doctors, in place of junsdiction, State Governments would consider the need
the present trend towards over-production of for expanding the pool of medical practitioners to include a
personnel trained in super-specialities. Major cadre of licentiates of medical practice, as also
portions
of
undergraduate
medical practitioners of Indian Systems of Medicine and
education, nursing as well as other Homoeopathy. Simple services/procedures can be provided
paramedical training be imparted in district by such practitioners even outside their disciplines, as part
level medical care institutions, as a of the basic primary health services in under-sen ed areas.
necessary complement to training provided Also, NHP-2001 envisages that the scope of use of
in medical/nursing colleges and other paramedical manpower of allopathic disciplines, in a
training institutions. No more new medical prescribed functional area adjunct to their current
colleges to be opened in the private sector. functions, would also be examined for meeting simple
No commodification of medical education. public health requirements. These extended areas ot
Steps to eliminate illegal private tuition by functioning of different categories of medical manpower
teachers in medical colleges. At least a year can be permitted, after adequate training and subject to the
of
compulsory
rural
posting
for monitoring of their performance through professional
undergraduate (medical, nursing and councils.
paramedical) education be made mandatory,
without which license to practice not be 4.5.2 NHP-2001 also recognizes the need for States to
issued. Similarly, three years of rural posting simplify the recruitment procedures and rules for contract
employment in order to provide trained medical manpower
after post graduation be made compulsory.
in under-served areas.
7.
The unbridled and unchecked growth of the
4.13 ROLE OF THE PRIVATE SECTOR
commercial private sector be brought to a
halt.
Strict observance of standard 4.13.1 NHP-2001 envisages the enactment of suitable
guidelines for medical and surgical legislations for regulating minimum infrastructure and
intervention and use of diagnostics, standard quality standards by 2003, in clinical
fee structure, and periodic prescription audit establishments/medical institutions; also, statutory
to be made obligatory. Legal and social guidelines for the conduct of clinical practice and delivery
mechanisms be set up to ensure observance of medical services are to be developed over the same
of minimum standards by all private period. The policy also encourages the setting up of private
hospitals, nursing/matemity homes and insurance instruments for increasing the scope of the
medical laboratories. Prevalent practice of coverage of the secondary and tertiaiy sector under private
offering commissions for referral to be made health insurance packages.
punishable by law. For this purpose a body
with statutory powers be constituted, which 4.13.2 To capitalize on the comparative cost advantage
has due representation from peoples I■ enjoyed by domestic health facilities in the secondary and
organisations and professional organisations. | tertiary sector, the policy will encourage the supply of
services to patients of foreign origin on payment. The
rendering of such services on payment in foreign exchange
will be treated as ‘deemed exports’ and will be made
eligible for all fiscal incentives extended to export
earnings.
4.13.3 NHP-2001 envisages the co-option of the non
governmental practitioners in the national disease control
programmes so as to ensure that standard treatment
protocols are followed in their day-to-day practice.
8.
4.13.4 NHP-2001 recognizes the immense potential of use
of information technology applications in the area of tele
medicine in the tertiary health care sector. The use of this
j technical aid will greatly enhance the capacity for the
■ professionals to pool their clinical expenence.
A rational drug policy be formulated that ■ No mention of rationality of drugs here or in the drug
ensures development and growth of a selfpoliqy
reliant industry for production of all essential
4 23 IMPACT OF GLOBALISATION ON THE
drugs at affordable prices and of proper
HEALTH SECTOR
quality. The policy should, on a pnonty
■ 4.23.1 NHP-2001 takes into account the serious
basis:
apprehension expressed by several health experts, of
the possible threat to the health security, in the post
■ Ban all irrational and hazardous drugs.
TRIPS era, as a result of a sharp increase in the prices
Set up effective mechanisms to control i
of drugs and vaccines. To protect the citizens of the
the introduction of new drugs and
country
from such a threat, NHP-2001 envisages a
formulations as well as periodic review
national patent regime for the future which, while
of currently approved drugs.
being consistent with TRIPS, avails of all opportunities
■ Introduce production quotas & price
to secure for the country, under its patent laws,
ceiling for essential drugs
affordable access to the latest medical and other
■ Promote compulsory use of generic
therapeutic discoveries. The Policy also sets out that
names
the Government will bring to bear its full influence in
■ Regulate advertisements, promotion and
all international fora - UN, WHO. WTO. etc. - to
marketing of all medications based on
secure commitments on the part of the Nations of the
ethical criteria
Globe, to lighten the restrictive features of TRIPS in its
■ Formulate guidelines for use of old and
application to the health
new vaccines
■ Control
the
activities
of
the
■
■
multinational sector and restrict their
presence only to areas where they are
willing to bring in new technology
Recommend repeal of the new patent act
and bring back mechanisms that prevent
creation of monopolies and promote
introduction of new drugs at affordable
prices
Promotion of the public sector in
production of drugs and medical
supplies, moving towards complete selfreliance in these areas.
9.
Medical Research priorities Te based on 4.12 MEDICAL RESEARCH
morbidity and mortality profile of the
; country, and details regarding the direction, 4.12.1 NHP-2001 envisages the increase in Governmentintent and focus of all research programmes funded medical research to a level of 1 percent of total
be made entirely transparent. Adequate health spending by 2005; and thereafter, up to 2 percent by
government funding be provided for such • 2010. Domestic medical research would be focused on new
programmes. Ethical guidelines for research therapeutic drugs and vaccines for tropical diseases, such
involving human subjects be drawn up and as TB and Malaria, as also the Sub-types of HIX’ AIDS
implemented after an open public debate. No prevalent in the country. Research programmes taken up by
further experimentation, involving human the Government in these priority areas would be conducted
subjects, be allowed without a proper and jn a mission mode. Emphasis would also be paid to timelegally tenable informed consent and bound applied research for developing operational
appropriate legal protection. Failure to do so applications. This would ensure cost effective
to be punishable by law. All unethical dissemination of existing / future therapeutic
research, especially in the area of drugs/vaccines in the general population. Private
contraceptive research, be stopped forthwith. entrepreneurship will be encouraged in the field of medical
Women (and men) who, without their research for new molecules / vaccines.
consent and knowledge, have been subjected
to
expenmentation,
especially
with
hazardous contraceptive technologies to be
traced
forthwith
and
appropnately
compensated. Exemplary damages to be
awarded against the institutions (public and
private sector) involved in such anti-people,
unethical and illegal practices in the past.
10.
All coercive measures including incentives
and disincentives for limiting family size be
abolished. The right of families and women
within families in determining the number of
children they want should be recognized.
Concurrently, access to safe and affordable
contraceptive measures be ensured which
provides people, especially women, the
ability to make an informed choice. All long
term,
invasive.
systemic
hazardous
contraceptive technologies such as the
injectables (NET-EN, Depo-Provera, etc.),
sub-dermal implants (Norplant) and anti
fertility vaccines should be banned from
both the public and private sector. Urgent
measure be initiated to shift to onus of
■
Refer to National Population Policy-2000.
i contraception away from women and ensure
at least equal emphasis on men's
responsibility for contraception. Facilities
for safe abortions be provided right from the
primary health center level.
11.
Support be provided to traditional healing
' systems, including local and home-based
healing traditions, for systematic research
and community based evaluation with a view
to developing the knowledge base and use of
these systems along with modem medicine
as part of a holistic healing perspective.
12.
Promotion
of
transparency
and
decentralization in the decision making
process, related to health care, at all levels as
well as adherence to the principle of right to
information. Changes in health policies to be ;
made only after mandatory wider scientific
public debate.
13.
Introduction of ecological and social
measures
to
check
resurgence
of
communicable diseases,
Such measures
should include:
■
■
■
14.
Integration of health impact assessment
into all development projects
Decentralized and effective surveillance
and compulsory notification of prevalent
diseases like malaria, TB by all health
care providers,
including private
practitioners
Reorientation of measures to check
STDs/AIDS through universal sex
education, promoting responsible safe
sex practices, questioning forced
disruption and displacement and the
culture of commodification of sex.
generating public awareness to remove
stigma and universal availability of
preventive and curative services, and
special attention to empowering women
and availability of gender sensitive
services in this regard.
Facilities for early detection and treatment of
non-communicable diseases like diabetes,
cancers, heart diseases, etc. to be available to
all at appropriate levels of medical care.
2.26 ALTERNATIV E SYSTEMS OF MEDICINE
2.26.1 Alternative Systems of Medicine - Ayurveda.
Unani, Sidha and Homoeopathy - provide a significant
supplemental contribution to the health care services in the
country, particularly in the underserved, remote and tribal
areeas. The main components of NHP-2001 apply equally
to the alternative systems of medicine. However, the policy
features specific to the alternative systems of medicine will
be presented as a separate document.
Ik
15.
I ■
■
■
■
16.
4.17 WOMEN’S HEALTH
4.17.1 NHP-2001 envisages the identification of specific
programmes targeted at women’s health. The policy notes
that women, along with other under privileged groups are
significantly handicapped due to a disproportionately low
access to health care. The various Policy recommendations
of NHP-2001, in regard to the expansion of primary health
sector infrastructure, will facilitate the increased access of
women to basic health care. NHP-2001 commits the
highest priority of the Central Government to the funding
of the identified programmes relating to woman's health.
Also, the policy recognizes the need to review the staffing
norms of the public health administration to more
comprehensively meet the specific requirements of women.
Child centered health initiatives that include:
■
■
■
■
17.
Women-centered health initiatives that
include:
Awareness generation for social change
on issues of gender and health, triple
work burden, gender discrimination in
upbringing and life conditions within
and outside the family; preventive and
curative measures to deal with health
consequences of women’s work and
violence against women
Complete maternity benefits and child
care facilities to be provided in all
occupations employing women, be they
in the organized or unorganized sector
Special support structures that focus on
single, deserted, widowed women and
minority women which will include
religious, ethnic and women with a
different
sexual
orientation
and
commercial sex workers; gender
sensitive sendees to deal with all the
health problems of women including
reproductive health, maternal health,
abortion, and infertility
Vigorous public campaign accompanied
by legal and administrative action
against sex selective abortions including
female feticide, infanticide and sex pre
selection.
1.
■
■
A comprehensive child rights code,
adequate budgetary allocation for
universalisation of child care services
An expanded & revitalized ICDS
programme. Ensuring adequate support
to working women to facilitate child
care, especially breast feeding
Comprehensive measures to prevent
child abuse, sexual abuse\ prostitution
Educational, economic and legal
measures to eradicate child labour,
accompanied by measures to ensure free
and compulsory quality elementary
education for all children.
Special
measures
relating
to
occupational and environmental health
which focus on:
Banning of hazardous technologies in
industry and agriculture
Worker centered monitoring of working
conditions with the onus of ensuring a
4.21 OCCUPATIONAL HEALTH
4.21.1 NHP-2001 envisages the periodic screening of the
health conditions of the workers, particularly for high risk
health disorders associated with their occupation.
■
safe and secure workplace on the
management
Reorienting medical services for early
detection of occupational disease
Measures to reduce the likelihood of
accidents and injuries in different
settings, such as traffic and, industrial
accidents, agricultural injuries, etc.
18.
The approach to mental health problems 4.10 MENTAL HEALTH
should take into account the social structure
in India which makes certain sections like 4.10.1 NHP - 2001 envisages a network of decentralised
women more vulnerable to mental health mental health services for ameliorating the more common
problems. Mental Health Measures that categories of disorders. The programme outline for such a
promote a shift away from a bio-medical disease would envisage diagnosis of common disorders by
model towards a holistic model of mental general duty medical staff and prescription of common
health. Community support & community therapeutic drugs.
based management of mental health
problems be promoted. Services for early 4.10.2 In regard to mental health institutions for in-door
detection & integrated management of treatment of patients, the policy envisages the upgrading of
mental health problems be integrated with the physical infrastructure of such institutions at Central
Primary Health Care and the rights of the Government expense so as to secure the human rights of
mentally ill and the mentally challenged i this vulnerable segment of society.'
persons to be safe guarded.
19.
Measures to promote the health of the
elderly by ensuring economic security, '
opportunities for appropriate employment,
sensitive health care facilities and. when
necessary, shelter for the elderly. Services
that cater to the special needs of people in
transit, the homeless, migratory workers and
temporary settlement dwellers
Measures to promote the health of physically
and mentally disadvantaged by focussing on
the abilities rather than deficiencies.
Promotion of measures to integrate them in
the community with special support rather
than segregating them; ensuring equitable
opportunities for education, employment and
special health care including rehabilitative
measures.
20.
21.
Effective restriction on industries that
promote addictions and an unhealthy
lifestyle, like tobacco, alcohol, pan masala
etc., starting with an immediate ban on
advertising, sponsorship and sale of their
products to the young, and provision of
services for de-addiction.
(The People’s Health Charter was prepared in consensus by numerous women’s, science, health groups,
people 5 organisations, voluntary groups participating in the People's Health Assembly process. It was
endorsed unanimously at the National Health Assembly at Calcutta held on ST' November and I5' December)
AGENDA ITEM No. 1
<■
I
i
2
E3
Ii
I
c
t
HE LTH
I-
Ki
1999
I
3
1
I
i
II
i
■I
I
J
I
s
GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
NEW DELHI
J
I
-'i
dkaft health policy
I
[contents
i
I
Subject
Page No.
1.
INTRODUCTION
1
2.
HE.ALTH CARE INFRASTRUCTURE
Rural Health Services
Organizational Structure of the Health Services
Urban Health
I
ENVIRONMENTAL HEALTH AND SANITATION
4
i
Health Risk Assessments and Public Health Institutions
Hospital Waste Management
Nutrition
4.
COMMUNICABLE DISEASES
Tuberculosis
Leprosy
AIDS Control Policy (In Summary)
Draft National Blood Policy (In Summary)
Malaria
Filariasis
Dengue
6
7
7
7
7
5.
S
Control of Blindness and Restoration of Vision
National Cancer Control Programme (NCD)
Special problems of Persons with Disabilities
6.
DRUG POLICT AND PRESCRIPTION PRACTICE
s
s
s
9
Vaccines
9
. 7.
8.
9.
PREVENTION of food adulteration
trauma and emergency services
10
10
INTERSECTORAL COORDINATION
11
the disease. The programme for
and incidence of senile cataract which
..............
1^i,NH"
1.8
SP«d-
■'» P-Jge or r,™ „e„
or malaria, once ilioughc ro hare been eradicaicl ■> I "
of d,seascs Irka plague, dengue
racing of prioridoa „d formula., „„ „f ne» appr^ad
^'i““
nave nccessitatec
production, water supply and sanir-itin
PProac le-s- espite substantial investments in the area of food
deficiencies, contaminated waier ill pHnnS urbanisaf mOrta‘ity C°ntinue 10 be e«cerbated by nutritional
increase in life expectancy anc chants in‘life TtvJe 1 a T
"T"™"'31 P011Uli°n- At 'he Same
communicable diseases like cancefdiabetes cardio vn
r'bl'|ted
Sr0Wins ‘^J^ence of noninstitutional care.
'
cardiovascular atlments, generating a massive demand for
1.9
Xz^^;::;;zsx;dt,rifrasTre in rurai—and
number of hospitals and beds both in the an
3 PafS °f ' ’e country- A1tliough there are a large
appropriate manpower, diagnostic and therapeutic"^''’ V° “ff7 and private sector- son’<3 of them lack
at places with the states with the lowest health indices^T 1^
ln‘er’State differe>tces have widened
burden of disease caused bv environmenml and
°
lnfrastn!Ctu^- The emet^ .g
responsibility so far targeted mainly to combattin" 00™°°'^ if0?
accentU3ted the burden of
technological advances, many of these have beef deni "?Un,Cable d'^ases- Although there have been several
awareness among the people as also ignorance about 1 ° "’T T' pOpulaUon due t0 lack of resources,
i0norance about services that they can rightfully
rightfully claim.
claim.
1.10 The 73rd and 74th Constitutional Amendment Acts of I OOP 1 .
■,
..
framework for the active involvemcmlf'X'cX
significant opportunities and
a
including Public Health and Sanitation. A orocess of
f ?
f
devcloPlllen! programmes
necessary to ensure that the district health atnhorities n H:^ntrallzatl°n and devolution of authority is now
coordination. It will be necessary to develop models 'to si 0C^panchayat leVel funcli°naries work in close
necessary to develop models
responsible for rural health
like sub m , "" 'T panChayatl raj lnstltut'ons can be made.
-.’J) <care institutions
•
•
■ active
Z 1'keiSUb-CCnlres and P^ary health centres and develop
sustain them further with the ;
and
'
£ Z ,nf°rn;ed part'a'Pation of the people. Decentralization is required
not only to fulfil the Constitutional j
P "ons but to make the primary health care services more efficient
and responsive to the needs of the local
-1 community. Referral systems and linkages between primary
secondary and tertiary levels of health < are institutions will need to be streamlined through incentive^
extended to entitled patients to receive fast track attention
----- 1 at each level of facility.
1.11 Most daunting will be the task of i
growing mtej-state disparities-and differentials in health indices across
the country. Reducing such disparities among States
Sub-districts
need
ilexibihty in (he
(he planning
planning process
process so
so (hat tfe^icVd'esZ'ffTf’ '‘T'3
ratcSlcs kcep area requirements in s iew.
Success will —
lie im the ability to restructure the existing
result oriented, to counter resistance and manage chan«e fl eT ! "f
f
participa^ry and
■ as a whole, will greatly determine the route thafhic “ ’ ?
f med13’ 112 Judlclary and civil society,
provisiomng of fndslnd appro X X
t
ZS "I
Wil1 be dle ad^-
poverty and illiteracy.
2.
P acllleve health °onls despite the constraints of
P
HEALTH CARE INFRASTRUCTURE
Rural Health Services
2.1
“to'eZ,ha' T eX,“nS
"
"I "“‘l
be !l'"•
P'"™? hPP'-l. enures are
'■P-rm,curing t|,c cxis,illg b|ock
fLilly operational
The gaps at
the
Ta|iik
cc
and Sub-divisional hospitals by utilizing the funds earmarked under the Basic Mini
" '
nimum Scr/:.ces package.
The current approach of allocating more funds to construct buildings for primary health
cen:res
and subcentres, and expanding the requirements of health workers, wtll need'to be supplement with
>
2 system
that
improves access to health tor the unreached sections of the population. ITiis would include makt"
adequate
Pr0H
„ h““”" 'TT- dn,SS "d
'='«'« »
level of faciu.y. eddixdS ft
problem o( abxcc.ee.cm ol guff, rcor mem.ecacce and icefic.eocy caused by poo, supcraisiea. ™gc'J
for a restructuring of the primary health care system with adequate autonomy funds and amh '
discharge essential medical and public health functions.
Uth°nty t0
\v
e
d
d
:1
Organizational Structure of the Health Servi ces
r
2.2
- sf:
le«e he du.,es end f„„ct,ons cf a„ hea„h SHff implem„„„, ,he hea|[h
available Io Panehayus and villagers. l0 enable them to demand services and draw altentio-’ to ft."
which ex,st at each facility. Encouragement would be given to hand
ov
he man - menV P
to ZZZ"”1 °f ,he
2.3
C dukKor*;
h“"h
” Z'”“
The adoption of a decentralised recruitment policy for filling vacancies of doctors in rural ar-as and the
mtroducnon of an element of limited compulsory rural service appears to be warranted b7the“uaenXnd
of doctors seekin. to work only in urban and peri-urban setr.nas. The local reeru.rme ci d” to' if
cessary on a part-.rme basis, will be pemtirted. The possibility of sub-cenrres. PHCs »1 district hesoLs
bums nrn m an autonomous fashion w.th the involvement of industrial establishments, cooperatives raljricus
; .he“zs?' rp'7djte ?!-;Cs_a^er_OPD±.ours.
pay rent and pr^tice a
In order to encourage in-^rvice doctors to functio'RTn'T^'f'a^
esZty s
health outcomes in other countries and can be tried selectively depending on situational requi~men”s
■2.4
(
Ihh”rd :°r es“b“in8 a s"™r f““l P»i"> » the district level for health, family welfare and women and
, d development schemes has been recognized. The States would h, encouraged to set op a distriX“d
y or overseeing the implementation of national programmes and public health functions.
r^^l'gh slhoolt^h rtft sSm.
“ a'0"""" “ “"’■’"'“n subjects a. the primary, secondary- and
\
he’alth promotion This off
e'ng “s“l dc“,elX 1° disseminate messages on preventive measures and
\ coherem and oordil. d
S ’"T?T“'l,ll‘"s f“ i"™"nation dissemination, which undertaken
a
\XkiZ “rad.
Ccould
°"ld bbring
™S ’about
h"1 ch
“
g
“
in
p™
help
inculcate
a
health
chang*
Urban Health
Y'o/
Zoe: (SoC5—-?cL
____________ ■
'
pUch !>
2.6
■ -A
h-G-O ifiy ,
cJ
---
Unlike rhp n»ml
and terdot, ™ s '
w
S'n‘C,Ur“i
“ O'™*
Secoodan,
,
.^ .
rvices in geographically delineated areas in the urban sector As a result p-’^or
ieconda^and^n?0"
h^,tb centres has taken PIa«
^ere has been a overcrowding a't\he
slums which have '^i
°Sp'lJ S’ As a dlrect result of urbanization, there has been a spread of urban
have madequate access to basic health facilities. The possibihty of mobilizing resources from
i jnc-oY'
Persies
/□<£- yoos/'ecL
ze. p&sKs^errr
;■
ENl care; obstetric care and new
,
•sm_.1c.11 services i.’.eludmg eye and
contraception; dental services- -meraenev 7
C '' J
‘ COllnselilnS r°r reproductive health and
non-communicable diseases Whe^/f^ >7™
7 preventlon and control ot' communicable and
made to build partnerships with the oriJateTd6’
°f
Up neW ‘^structure, efforts would be
particularly necessary in the case of urha ? V° Uata^'aectors t0 Provi(:le basic services. This would be
where the people for lack of 4lv r
17 *
f°r overw^™ng concern
-ie!y primary health care eventually become a burden on the city hospitals.
3.
ENVIRONMENTAL HEALTH AND SANITATION
3.1
Environmental factors (in Darrimlnr
• l,
.
mortidky and monali.y, apart from «U.<i™„'a\SdZZ=S™“ZePpZpa|«Cr‘,Ciai
" r™”"8
3.2
direct responsibility of^L'TeX'sTioZtbaT’lth Z ’nd ”l,d WKte manageo.ent would be made a
3.3
drawn attention to which has b-en amona r| '
7^ S ' S large SCale S°li and Wat£r PolIution are
related and water-borne diseases n Zl
7 attributable for the
P^alence of soilmseases m rural areas and the spread of infection in urban and peri-urban areas.
to a sale d^^a^
substantially and the norms for defining the distance
■° - -..—. .i xxxzzr sr°™d—-d
Water Quality Surveillance would e
3.4
'
,n
’
Water sources’
ZX’XtinsZmtimefnin" She'PZ“‘ l'y8iC“’'’“‘T “d *'
reguhr habtis. heeldTdueat.om “ a diZ Z X r “TZ.
ailments and injuries etc. would "be reinforced
,radi«io<«‘' Pilhre
“d’
C'VIC ValUCS’ 110me treacment for minor
' '’
A
3.5
X
S
^“made
Zpunishable.
Ed
made —
mandatory X
and ±
suppression
of data
and other diseases will be
Jlenlth Risk Assessments and Public Health Institution-:
. 3.6
Given the accelerated pace of indiisrrinlicnf^o
planning stage itself. Before the const'ctionTn 7 "T
,
* 7^
t0 be addreSSed at the
stone quarries is taken up, a health impact assessment^0?63’
P°Wer Plan'S’ damS’ m‘neS °r
funds for addressing the emersinAZ? n '
Z
'7
7
'0 be
°Ut and the
the implementation and maintenance phases" There '
f°"nulatl°n of the ProJect “ cover
existing pubiic health mstitutions and rea ona’aid S a hhp
? Substantially lengthen the
address preventive health care inrmunS 7 7 br I laDOrat°rleS'Essentlal P^c health functions which
priority. The capacity to undertake labo 1
‘
S 77 P
a‘th reSpOnSe SyStem wiH receive
health functions.
3.7
°
§
deVelOped and Wl11 reCe,ve the stat^ of essential public
d,s''“'rou“be s““?,hen£d ■t>'
fez
’
- rr “7“"4“
be accessed and a model suitable lor Indian conditions introc need in order to build a reliable epidemiological
base to plan public health initiatives.
Hospitnl Waste Management
3.8
All hospitals in the country whether in the Government or Private Sector are now required by law to initiate
an appropriate hospital waste management system. Each hospital would have an infection Cor.irol and Waste
Management Committee to devise policies and segregation of waste and infection control. The provision of
incinerators/appropriate method ci waste disposal to be installed in hospitals having more than 50 beds would
be monirored. The establishmen: of common incineration facilities would be encouraged. Tr.e enforcement
or the law would be undertaken cy involving the public in o\ .Tseeing compliance and reporting shortcomings.
Nutrition-
i Tt
C
3.9
Food and nutrition security for rhe vulnerable section of the society would be viewed not only as issues
concerning the science of nutrir.on but would be rela ed to the right to work, the right to health, the right
to education and the right to information, all of whic i are dependent on a healthy state of mind and body.
Within the overall ambit of the National Nutrition Policy, priority has to be assigned to the equitable
distribution of food to all inducing women and girl. Pregnant women and nursing mothers constitute one
of the most important target groups particularly as investment in their health and nutrition directly affects
the birth weight of new bom cnildren and their development. The need to start complementary' feeding at
six months and for tackling malnourishment in the under 5 age gr up are two more interventions which need
to be augmented where critical gaps continue to persist.
3.10 The lack of iron and iodine intake also need to be given reinformed attention. Micronutrient malnutrition
is not confined to India but is accepted as a global problem. Investment in assessing the magnitude of iron,
Vit-A and iodine deficiency with sustained intervention strategies to improve dietary intake of micronutrients
will be provided for within sectoral allocations.
3.11
People’s.own responsibility for their health at the level of the individual and the family would be given
appropriate focus. Imparting health nutrition education in terms of knowledge as well as practice will be
given a major thrust to help people overcome the aggressive marketing of consumer goods and services often
injurious to health.
4.
COMMUNICABLE DISEASES
4.1
The health status of a people is determined among other things by the availability of safe drinking water,
sanitary disposal of human waste and other wastes, adequate nutrition, literacy levels, educational attainment
and the status of women. Health outcomes are mostly the result of activities and policies that fall outside
the health sector: agricultural output and food production, poverty alleviation programmes in the area of rural
employment, education and social welfare, housing, water st.pply and sanitation etc. Health outcomes are
also dependent upon non programmatic initiatives such as governance and the capacity of the regulatory
systems to enforce the rule or law related to food adulterati- -n, maintenance of prescribed standards in the
manufacture and sale of drugs. An integrated and multisectoral approach is essential for implementing
health programmes which would have a direct impact on the c.isease profile.
Tuberculosis
4.2
Tuberculosis remains one or India s most serious health problems and has been identified as one of the
hot-spots for multi-drug resistance. It is estimated that there are 5,00,000 deaths per year from tuberculosis
5
P- the COl'nl7>M-rrpe lh?n-,’CC0 CVC'7 day- ' CVCry '”inute- Thc Rcvised Na[ion:11 Tube-culksis Control
io r.immc
) is icing expanded in a phased manner across (he country. In the next 1(1 veins, the
cha lengc lor prevention and cvntro! of tuberculosis will be to implement RNTCP (hrotm'-.out the country
while ensuring high quality of service delivery. For this to happen, the capability of uncertaking quality
diagnosis will be upgraded through the provision of essential equipment. Increased access to quality 1
microscopy services, uninterrupted drug supply,'directly observed treatment at a place ccnvenient to the
P^mnt, and the introduction of new reporting system will be implemented countrywide. In addition ■
HIV-associated tuberculosis is likely to increase in the coming years and could greatly increase the burden
of tuberculosis in the country. Therefore, new strategies will be introduced to reduce the burden of '
HIV-associated tuberculosis. ‘
;
Leprosy
4.3
With a significant decline in the number of leprosy patients due to effective cure with muki-dnit; therapy
it is expected that leprosy will be eliminated in most of the States/UTs by end of year 20CC: the remainins
States may take up to year 200?. The present trategy of detecting hidden cases and treating them with MDT
will continue. Eflorts would be made for pi >per integration of leprosy services with general health care
particularly for ulcer care and attention to the problems of disabilities. The need for socio-economi-'
rehabilitation of leprosy cured persons having disability beyond grade II will be given priority.
AIDS Control Policy (In Sumnmrv)
4.4
The problem of AIDS is a public health challenge and will continue to be treated as a matter of great
urgency calling for commitment, effective implementation of the programme, provision of accurate
information and education to make people aware of the need to protect themselves from HIV infection. The
State will introduce a helpful and supportive social environment so that people who suspect themselves to
be mlected can come forward for voluntary testing and for seeking help so that they can live peacefully with
other members ot the society. Special efforts would be made to remove fear psychosis from the minds of
people and prevent discrimination and stigmatisation. While a separate AIDS Control Policy is under
formulation the notable elements would include:
Development of a rstrong ownership of the HIV/AIDS Prevention and Control Programme by the Centre and
State Governments.
Strong advocacy and social mobilisation from the top most level in government to ensure the spread of the
message throughout the country with full cooperation of NGOs and Community Based Organisations.
:|:
*
Promotion of low cost care to people living with HIV and AIDS without any discrimination and
stigmatization. This would include encouraging systematic attempts to create homes for people with AIDS
who may no longer be able to live with their families.
.Promotion of management of Sexually Transr
.nsmitted Diseases (STDs) through a syndromic approach.
*
Expansion of targeted intervention s:
*
Reduction in transmission of HL'efforts to increase voluntary bloo .
d by transfusion of blood and blood products by mobilisation of
:on and screening of blood.
Strengthening the effectiveness of
ogrammc through technical, managerial and financial support.
‘cgies for high risk groups of the population.
Expansion ot S FI/HIV/AIDS sentinel surveillance and operational research programmes.
6
tr 'A
-ol
he
Inter-sectoral and cross-sectoral collaboration with the public, private, corporate sectors -■> invol
in responding to the problem of HIV/AIDS
P
sectors
involve citizens
TV
ty
cy
he
n,
:n
'7tCT.'Z.
*
reS'“h efF“ "°“ld b'
” deVe'OP dn,SS’
>*-■ i" a .ime boond
Draft National Blood Policy (Tn Summary)
A
4.5
The recent Supreme Court judgement on Revamping of Blood Transfusion Service has F-nnoht •
the urgent need for streamlireng and managing the blood trnnsteion services in the'count7°“’
heeustng of Blood Bmtks. the elimination of the professional donor svs em Xe r="5o„ „ n
“b
Cosmetres Rules to prescribe standard proc.tces have already been
ZiT Gorem “ nj ,
to make adequate and safe blood and blood products aeatlable win be re,forced. A separL- Na“Z”d‘
Policy which has been formulated would set out the guidelines and directions for better mar^ement of blood
bansfus.cn servtces, gtv.ng meanmght! encouragement to btaod donation, expansion of bkZd rep” io an j
component fac.l.t.es, p ased .ndigenisation of blood bam: equ,potent and testing kits andZTh“s »
biosafety measures as they relate to safe blood. Screening of blood would also include HCV flon.wilh
the existing four diseases already being screened.
aion3with
Malaria
4.6
otng programme with 100 percent Central assistance in the seven North-Eastern Scares and the tribal
dtstnets of the country where the prevalence of P.falciparum malaria is high, will be continued The
enhanced malaria control programme will also be implemented in all districts, cities and towns having a
rising shde-posmvity rate and in areas where there have been focal outbreaks of malaria Ln previous years
he mam components would include early diagnosis and prompt treatment through stren-Jiening of active
and passive surveillance, laboratory diagnosis; selective vector control by integrating various sector control
pproaches promotion of personal protection methods; prediction, early detection and effective response to
lana outbreaks, and intensified information, education and-communication campaigns. The invobement
of the community m ±e prevention and control of malaria will be given the strongest emhasis with the aim
of eliminating mosquito breeding through people’s participation.
Filariasis
4.7
rino the Ninth Plan, the strategy for .filariasis control would include single dose DEC mass therapy
bw introduced in a phased manner to eventually become a National Programme. Vector control
would'co’t
eCtlOn
treatment °f miCrOflIaria carriers’ and treatment
acute and chronic filariasis
Dengue
4.8
?dn r- 0 enjUreJ at
households implement peri-domestic measures to reduce the breeding of Aedes. The
.round11 rn enrorcemen[ of urban bye-!aws Will be pursued so dial those responsible for creating breeding
mtr du ed0,?01’”'^'!
Td=
fW ,,,e S™'- A
Control Prognamree would bj
introduced to cover the high nsk areas of the country.
7
I
5.
CONTROL AND PREVENTION
OF NON-COMMUNICABLE DISEASES AND EMPHASIS Or
OCCUPATIONAL HEALTH
5.1
Life-style related diseases are at times
a concomitant outcome of increase in life expectancy ns wpII ,
industrialization, urbanization and i
to the burden of disease.The thrust
organized health eduction campaigns aimed info
C
W°U°n e2~'Iy preventI0n through
of the dangers of rich diets in saturated fat salt and
P°PU 7°° lncludlns c‘":ldren Md young adults
to tobacco and alcohol. The magnitude of the m
ones’. ab^nce of physical activity and addiction
standardised surveys. National and State svsm
n0n‘u0nnnunicable d|seases would be assessed through
■
otate systems would be set up for vital reo’isfr^-’nn Tn
j
prevention strategies would be developed
J 7
registra_on. Targeted primary
interventions for both diagnosis and nrimarv tr?-,, P ° "1 mm
6 demo8raPh‘C transition cost-effective
centres and rural hospitals will be introduced in a XT d nOn’CO™mUnlc:lble dlseases at the primary health
aimed at creating cost-effective models suitable for ruralToTdkwns^0"
W°U1<?
m°Unted
5.2
5.3
The health infrastructure would be involved in
' '
monitoring, the provision of occupational health care by
gen=ra.i„g dao on occupMio„aI diseascs ,„d mating ,he
. . > responsible for prevention and treatment,
ex.o77™b777o7by‘«c”p°a“,0„7'i?e““Sd “
to highlight r*
product’s having toXXTbold to'war'mnXf0'
people. The advertisement of tobacco nroducts
d"T''5
in£r°duCed with al1 ‘^CO
" ‘TT'X d'irectI0n easily "''eHigible to even illiterate
Control of Blindness and Restoration of Vision
5.4
5.5
’"<l
eneoaLd to use
intplant xurgery would be standardized with „ emphasis on sight
‘0L
taS
National norm, wotdd be dereioped for the diat-nosis J management of ghucoma at the pj teref
National Cancer Control Programme (NCD)
5.6
expee,™, and ci.777/ irr/sTyVe'CTbere
d:xzzs Tgis“d r
xs
pa.ien.a. The slraKg, under the prosramme would Inelude faZduXrXd”- Ton”"^'”"
wbleb are
expended
vast majority of the population.
Special problems of Persons with Disabiljties
5.7
In the new - Person.,
P
with Disabilities (Equal Opportunities, Protection or Rights and Full Participation) Act
1995, the seven
... categories of d,sab,lite inch,do blmdness. iiw eision, leprosy that has been cured
8
there is a loss ot sensation or deformity causing social and physical embarrassment, hearing impairment,
locomotor disability, mental retardation and mental illness.
5.8
With the introduction ot the Prevention of Disabilities Act, 1995, centres for Rehabilitation will need to
be set up at the District Hospitals. The existing health infrastructure would be strengthened to incorporate
provisions tor the prevention of disabilities and rehabilitation of the victims. Each State and Union Territory
would ensure that PHC doctors and para-medical personnel receive training and are given orientation in the
medical aspects of rehabilitation. Strategies would need to be devised to overcome the m^ahs, misconceptions
and prejudices surrounding disabilities and deformities which have been a hinderar.ee in undertaking
meaningful efforts to rehaoilitate the disabled and make them productive members of the communitv. The
recommendations of the Medical Council of India to start Physical Medicine and Rehabilitation Departments
in every medical college would be implemented.
5.9
In all poverty alleviation programmes, priority would be given to actively involve persons with disabilities.
District hospitals would be strengthened to cater to the medical rehabilitation aspects. ?HC doctors would
be sensitized to provide early and special treatment to patients with disabilities. Health and safety measures
would be promoted at the work place, home, public places and public transport.
6.
DRUG POLICY AND PRESCRIPTION PRACTICE
6.1
Within the overall framework of the Drug Policy 1994, a National Drug Authority will be established to
oversee inter-state commerce and undenake central registration of drugs.
6.2
The Proceedings of the Drags Technical Advisory Board and its decision to withdraw hazardous drugs and
those of questionable therapeutic value will be published in relevant publications for the benefit of the
consumer. The Central Drug Control Organization would be strengthened and new Central Laboratories to
cater to Regional needs established.
6.3
The capacity to undertake drug testing would be augmented by providing additional equipment and
manpower and undertaking appropriate renovation and modernization of the laboratories. The enforcement
staff at Central and State levels would be strengthened and their capabilities enhanced through specialized
training.
Drug package labelling will compulsorily have to carry proper drug information and consumer warnings.
Pharmacists will be under instructions to warn consumers about side effects of drugs. The concept of Over
The Counter drugs and prescription drugs will be defined and administered through the licensing authorities.
. J5J
The essential drug list which has already been declared for different levels of health facility will be adopted
countrywide so that there is uniformity in approach. Surveillance on patterns of drug misuse and on
monitoring of adverse drug reactions would be undertaken and reports thereof discussed al the Drug
Technical Advisory Board and published for consumer information.
6.6
The indigenous production of testing kits for Hepatitis ‘C’ and HIV/AIDS will be encouraged.
6.7
The country is self-sutticient in production of all the vaccine required for National Immunization Prcsramme
except Oral Polio and BCG Vaccines. The Polio concentrates arc imported blended, bottled and
supplied to the States. 60% requirement of BCG Vaccine is fulfilled by the indigenous production and the
rest (40%) is imported. The efforts would be continued to attain complete self-reliance in the production
of vaccines.
9
6.S
p"H,c &a" Tid be as“,c<i ,o ras“"°
a"-d
“'* »r>J eorr.oioiog ,|,c
prices of ossenfioi voecir.es'inrenid Zh ”" “ 7"
would be corporatize through loi r
' nnmumzatmn programme. Whenever possible, they
orporatiz. J through joint ventures to make them function cost-effective?...
6.9
°f RabiCS is VCry painflli
at
«Pable of
vaccine will be encouraged and die trad^tionT001'3 produCtlOn, °f a morc safe and receptive tissue culture
r^ttional neural vaccine phased out. I
6.10
Considering the threat of Yellow Fever 17^
the Asian Region, the production of Yellow Fever vaccine
restarted in the country will be augmented
as a precautionary measure with the surplus made available
for export.
7.
1 REVENTION OF FOOD ADULTERATION
7.1
Programme bot’h at the Centraa°7^
Food Laboratories, tramit ^Lff eTt b I
Na,ion:“,
A Naii™ai F»ad
WOuld 'nC‘ude establishment of new Cent
augmentation of the Central and State food l-ih'i T'
mpOr' ^t|'n ‘ty Con[ro1 LniIS :lt tlJc Ports and
as quantitative analvsis of haldou uX
T
T. .6
t0
SC'’Sitive ^‘s as 'vcl1
would be given priority.
substances. The establishment of District Food Inspection Units
■
7.2
7.3
Z"
PaT““y
”d a'“nd P1”” *«X*. like
quZ Z” zzzZd P„b: rz' ,l’roi's” r ""andiliaNSS
and ~'""'"
“,e rS ” °f F°°d » sense of
awareness oboe, heal,I, L,ds
7.4
Designated courts would be established
to see that the trial of food adulteration officers is efficacious and
swift.
8.
TRAUMA AND EMERGENCY SERVICES
8.1
7 X* *1^.C0U,t 10 a“M'^
established i„ all hospi.als ru„„
aZhZ
» be accessed. ne.L.ZZZZ
P
>" »y Lih.1 and
Z C°mn’unica,i°n “d “irel'as links wonld be
’““'f ““
8.2
high risk spc.s on Nal P
H Z.VS 7
'V°“
“ aa“r “
'-h the H,ghway Authority of India and
Telecommunieauo,, authorities.
8.3
1"’,?‘''L“d'
Policies and schemes to compensate private tertiary hospitals which volunteer P to treat accident victims in
ic wa x 0 urge scale disasters would be introduced to reduce the unmanageable load
—1 cast on public
hospitals during such emergencies.
load
10
9.
INTERSECTORAL COORDINATION
9.1
Intersectoral co-ordination between relevant departments would be strengthened so that the preventive
promotive aspect of healtr. care are integrated and propagated through the existing extension arms of the
government machinery. A close partnership between voluntary organisations, private practitioners and local
government infrastructure networks would also be developed so that the spread of health education messages
becomes a universal responsibility.
c
10.
HEALTH CARE FOR SPECIAL GROUPS
Health of Women
10.1
Girls start working earlier than boys, work longer and harder throughout their lives. The energy consumption
m mere survival tasks of - fetching fuel, water, fodder; care of animals; washing; cleaning which are
exclusively women s responsibility results in a negative nutritional balance and calorie deficit The
programmes on AIDS, STD and Family Planning would be integrated so that women can have access to all
the inputs through a single source at the primary health level. The large number of abortions and abonion
deaths reflect the increase tn the number of inflicted, unwanted pregnancies which women have to bear These
contribute substantially to maternal mortality. The non-availability of trained attendants for deliveries would
be corrected in a time bound manner by laying down targets for yearly achievement.
10.2 Changes in medical and nursing curriculum would be introduced to incorporate women’s health concerns.
10.3
A separate Population Policy would be announced. Hitherto, public policy has been restricted to the
reproductive health of women. There is need to broaden the framework and provide women access to other
services. This can be possible only when health care delivery is fully integrated. Health will also need to
be centred within the broader context of empowerment of women and interrelated to the overall plans and
strategies of the other related departments working for gender equity.
Health Care of Children
10.4
The largest mortality amongst infants and children takes place under five years of ase mainly on account
of low birth weight, respiratory diseases, diarrhoea, malnutrition, measles, the outcome of improper
antenatal, natal and post-natal care and premature birth.
10.5
Children are also engaged in stressful conditions in agriculture, hazardous industries, domestic jobs. etc. The
health of children has to be safeguarded through special health check-ups which will be organized in
conjunction with other activities aimed at checking child labour and uplifting the quality of life of children
Reporting of causes of injury in the.case of accidents involving children will be made mandatory so that
corrective action can be taken including the use of penal provisions where called for
10.6
The enforcement of the Child Marriage Restraints Act which will help in reducing the number of teenage
pregnancies will be given nationwide priority so that society at large is involved "in preventing the illegal
marriage of girls before the age of 18.
• o
10.7
Special attention would be given to the nutritional status of adolescent girls and pregnant women through
the Reproductive Child Health Project and the health services strengthened so that children get proper
protection and timely treatment against the common diseases of childhood.
10.8
Universal immunisation of children against vaccine preventable diseases, elimination of polio and near
elimination of Tetanus and Measles would continue to be a priority
'
•-
11
i A cocu•
1 t
.-Lf
Elderly persons
The concept of geriatric ccare would
....
be introduced into hospital services at all Ic* els. both in urban and rur:
10.9
areas. Special erforts would
i
........be
J HKide
to address die health component of the p< hev on aeinu - narticulail
...
•
*
—
»
intioducing die promotion of health
giving life styles and freedom from psychoscv
ial pioblcms aS an csscnti.
component of core for the elderly.
iKj L^S-i /l^
>roI
l>)qci(2. r-z
Mental Health
^5
-XT
.......
acceptance wtthm the community. Nervous disorders constitute the highest burden of disease and thev affec
women predommantly. Anti-depressant drugs would be stocked at public sector health centres and hosp.tal
at
te sub-dixts.cnal level and measures taken to address the social stigma attached to mental illness
'".H The unprovemem of mental hospitals and Departments of Psychiatry tn general and teaching hospnal
Un,'S 0 ‘,tLqu‘llc ■stafl ancl services wdl be given priority attention. Regular and adequate supplh Z cen'Z ICqi"
lre:ilmCnt °f thC "’entally m WiI1 bC enSUrCd
distri“ ''U^ls ;•
10.12 The pilot community mental health
programme under implementation for the primary health can] level wonk
be expanded.
IO.'3 exislihg „,c„lal hbsi.ibds
be eetaed
,,c ..^ded .,s l!c?i„,Kll „,„res (er
I heaid
and loi .standing as examples of best practice lor surrounding areas.
10.14 Oep«„1™1S of Hyehie.ry «o,.|d bo cre.hod In all
™ “ I ,'he dee f., “fj ^7” f'0''
n.edienl errlleger .„„( ,|,e
"Ca""
|„J . .................
.. ......... L,rv h7hl
"™"‘l
doctois. Stall and community trained to recognize early sitins of mental problems -o ilm'h. , i ■
treatment and follow-up of mentally HI persons are tntegrated with the- community through d.fferent welfare
W.I5 The Ceibral and S.a.e Menul Heahh A,aln,™„ „„U|J p,ay an eftai™ „,|y
„„ cxis„,„.
agiala »» and ,„easareS „„„W be laeeJeced ,0 See (ha. every ,.,e„,al hospaal. i,s
apeaed by g.eup.s of p„|,|ic splrlK(|
p„iodica||v
afb lae.a.es .a
c|
’
visitors and authorities set up under the Act.
'
Dcntnl Hculth
10.116 Oral health would be made an tntegral part of the general health policy and separate Directorate established
to pursue the pubhc health aspects of proper dental care. Dental colleges would be asked to s a ]d'l
□ !■’,»
p^ve
„c=d by pbovd,,,.,
„Jci
„„„„
nily dc„,’try.
„a, slJrgeons bol||
ihe
.k.
F
I ,
'
would l,v pu.d lor services rendered on the basis ol case tinding.^,^
11.
SYSTEMS SUPPORT FOR HEALTH SERVICES
Voluntary Svclm- iu I R-.ilt h ( arc
H. I
W hilc vohintarx tmenctes ami NG'Os have been used evtensf.els- in implemenlitm health sector programmes
and this v.oulJ be
"imued ami exp.-.mled. Imam m elicit their -.-cv.s and to deal e.ith eenerte'ep'eraiional
12
problems would be established :SO that the interaction is meaningful and continuous and there is a formal
body to take note of ihe need for
mid-term correctives. Voluntary agencies a.-.d Community Based
Organisations would continue tto be used for the effective implementation of National Programmes as well
as to spread health education and
-d act as a watch dog over the provision of health services within the public
and private sectors.
Health Finance
I 1.2 The share of public health i
ln f e exPenditures of the state governments would be increased annually and
the focus would be on <conso i ating and improving the existing health structure and system rather than
spending on expansion of infrastructure. F
Facility wise list of procedures alongwith a check list of equipment,
drugs and consumables would be available
e at every district hospital, community centre and primary health
centre for public information, Maintenance of facilities will be separately provided for in the State and district
budgets.
11.3
Government hospital;
are clearly unab e to pay get free or subsidised treatment. Guidelines and norms for deciding payins capacity
will be evolved limitea to other economic indicators.
” H
I 1.4
The need to mamtain national health accounts to monitor health expenditures will be given concrete shape.
xps_n iture wou
e ^viewed activity-wise to oversee the actual returns on investment so as to introduce
timely corrective action.
I 1.5
Research and experiments would be undertaken to create financially sustainable models of free health care
for the poor in rural and urban areas.
Relevant Technology
Health Management Information Systems
• 11.6
11.7
11.8
Priority would be accorded to fthe establishment of Health Management Information Systems which are able
to identify the gaps so that resources can be assigned meaningfully. The benefits of computer technology
have so far percolated into imedical
" ' colleges, research and training institutions. Small projects for data
collection at the district level,, 1E mail communication through the satellite and modem techniques have been
introduced on a pilot scale but their universal application is still
- ---1 many years away. The collection of
information in a continuous fashion to enable correctives being introduced7 i
- in a timely manner will therefore
need to be achieved through the use (of~ modem systems of data processing. While this will improve the
efnciency and effectiveness of the health
...a care system, it will also facilitate better policy planning.
measnrina
r0**
deve^0Pment and te$ting of appropriate inexpensive technologies for
the phc" ''ei|SJ C and he’ght t0 fac:Iitate earI-v detection of under nutrition in adults and children: in
multi nnrTS
rei.0
SFStrUm£ntS fOr msasurin? aner!al diood pressure for use-by ANMs/male
introdX
and land'held electronlc data entry machines for ANM/MMPW will also be
introduced in a phased manner.
Tories ind
tTJp t?3''6 t0
3 diStriC' daU baS£ °n heakh manpower belonging to various
can be usei effedi! I
Practlti°-^ irking for government, voluntary and private sectors so that they
effectsely in promoting nealth care through proper orientation and trainin-
13
12.
PRIVATE HEALTH SECTOR
12.1
‘° C"C.0UraSC the Priv;lte sector and
them an ending environment to (level,
class medical -7 J S
d'agn0StlC centrcs ol c’uallty ls recognizcd. The:; potential for providing hi: re conserving previous foreign exchange which would be spent in having to sei
adZceT
°ad f°r treatment as wcl1 as [heir caPacity for attracting foreign clientele in search
anced medical care 1S recogmzed. None-the-less. the other side of die coir, represented bv the existen.
of poor quality, unregulated nursing homes and clinics is also a reality.
'
Regulatory measures fojLPriyateNursing Homes and Hospitals
12.2
L-7 WOfld be enacted t0 provide for registration of only those private hospitals which
have minimu;
facilities.for difrerent forms of treatment. I' ' '
‘
Monitoring mechanisms would be developed to ensure that th
facilities and sen ices created in private and voluntary sector hospitals
; are available and maintained at'th
esire evel. P.ivate Hospitals in non-conforming areas which
are posing health hazards would b
recommended for being moved to conforming areas.
12.3
Medical care in the private sector has so far worked in isolation without being accountable to any regulatio
even self-regulatory mechanisms. Juxtaposed with some of the finest examples of world class meo
-- -stances ot callousness, negligence and poor quality care continue to be’reported. Although publi
s itutions are beset with similar complaints, the existence of internal supervisory systems media°attentio
and parhamentary vigilance, have to some extent protected the rights of the puo^c. h the a£ce of sue
“ TS
the pubX‘is’paVng Ct^Tvtl s"'0'
12.4
r?SUla“°n’
cular'y
The States will encourage the establishment of accreditation mechanisms to give a star ratine to each leve
of facility and his mformation will be made available through Directories on medical facilhics for publi.
ZZeau of^XisIl'T in Ur abSCnCe °f 3 Star,cJard-setdnS asency will sought to be filled tlmougl
evolve?,
12.5
Standards the Med.cal and Nursing Councils and the Consumer Forum workin" together c
A Council for Medical Care Standards will be established which can function as an independent regulator
body for the country and all
I U r
new estab!ishments'will be required to fulfil the standards nrescribed bv the
unci , c ore getting clearance from the appropriate accreditation authority. Existing facilities will be vj
m ed period to attain such standards. The Council will grant recognition to accreditation Cciu i s a° the
St te and dis net level winch will have powers to levy charges for registration and renewal A Charter X
consumer'
12.6
t
' Sl'SSCStCd f°r be'"E adoPlcd voll"11;ld>y by the hospitals for the benefit and guidance of the
n10031 b°dieS W0U,d introduce incentives and disincentives to make for the dispersal of medical
L neZ'medical anTd S
" Urban areaS’ They would deciare * Policy on establishment of
P
d ,
d dlagnostic centres, nursing homes and clinics would address the conc-m of smtial
uny T e Medical, Nursing and Dental Councils will be enjoined to play a more effectZ ch£
nca aspects of private practice including over pricing and profiteering at the cost of the i^noram
consumers.
12.7
irnmH lmPle,11Cntmg d,e exist‘ng Acts and laws, an entirely new range of comprehensive regulations will be
n oduced to prescribe mmimum requirements of qualified staff, conditions for carrying j'Zialized
r ui ions an proccdutes within a set of established procedures for quality assurance The maintenance
i'X’ .tesx;" ™x u'e abscn" °f "as prc' c"''d
14
acii°"
I
. U.S The subject of quackery would be tackled by making registration of al! medical practitioners under the
relevant State laws mandatpry. Non-registered.practitioners would not have a right to practice medicine and
the judgement of the Supreme Court in respect of medical practice woulc be enforced.
Social responsibility of Industry
12.9 The corporate sector wall be expected to respond to the challenges in the area of primary health care, as part
of community development efforts in rural and urban areas. The sector would be expected to sponsor
information and education programmes on health issues, using modem professional skills of advertising and
public relations, using various media as a part of this social responsibi’ity. A legislation which wouldTek
this mandatory service would be introduced and the funds spent on f :a th promotion included in the annual
report of each company engaging more than 100 workers.s
‘//7T^3
. ,
13.
sOj-i(jLA/tJL
(3xa.IcL
xoA
eo
/Oe*
I
<rQ
<rQ
c-*ir <2
ex &
MEDICAL EDUCATION
Policy Objectives
13.1
Maintenance of high standards of medical education will continue: co be the primary policy objective within
the overall ambit of the National Health Policy. In addition, the endieavour shall be to bridge the gap between
availability and demand for medical manpower in rural areas and to ensure that the quality of medical
____ is socially relevant.
education
.
. p rf
'
/7/3' jt* * i /)//
•/
fi
c.
c cy
o tu-Vex
(x-r
/1
j
<ctL Kc>
kj o r~) ~ n>^6/1Cj
c:i.ppir<zp r icy<^
<^.
^ress11i'e]7iX?r avtiila^Ylitv ^nd need of rhedicaf marmower
•
13.2
For making an assessment of the availability of medical manpower and future needs of the country it shall
be prescribed by law that all medical personnel (including dental and para-medical) shall get their registration
with the appropriate technical Council once every five years. Provision shall also be made for registration
of additional qualifications/super-specialisations in order to create a data base on manpower in various
specialities.
13.3
The existing medical and dental institutions shall be geographical; / mapped and areas of the country found
deficient in such infrastructure will be given preference for estabiis ling new facilities. Establishment of new
medical and dental colleges within the same area will be discoun ged* ad sustained availability of qualified
medical teachers made a criteria for determining the establishment of more medical and dental colleges.
Increasing availabilitrv of medical manpower in rural areas
13.4
The recruitment of medical personnel will be decentralised and powers vested in the local bodies for making
such recruitments. Skills of para-medical personnel will be upgraded to enable them to provide basic
medicines even in the absence of a medical personnel.
E^tructuring of the Profession! Co'undb;
ci
3.5 Thv, Councils will be restructured in order to enable them to be responsive to changing social requirements.
All Staces/UTs shall have Councils to represent the Medical, D mtal. Nursing and Para-medical professions
i lat are comprised of elected representatives of the concerned professional community. Efforts to weed out
unqualified medical practitioners shall be renewed. The Professional Councils would be strengthened to make
t icm e ective in maintaining standards and encouraged to become self sufficient bv raising resources through
re-registration of doctors.
'
5
15
13.6
13.7
While the positicn of the Coi ‘I
for them to interact with rcprese'uatives of^0115
pr°fessional bodi« ■viH be
be recognized. A forum lor exchanX "f (
SCCt,0,’S °f SOcicly who need I ■ maintained, the need
health care the most would
country needs can be deliberated upon w'^
UP WhCre 3 mOre re-,istic
rendering of what tii£
' T P°n W,th representatives from the social
consumer groups as well
professmnals from Nationll level training and reseat
sciences, voluntary agencies,
centres.
The Indian Nursing Council and Snr v •
and monetary support to enable themtofeeXlaVZs^d^t 'V'
effeCtive thrauSb technical
regulate the standard of
---d which place reliance
- - «f - XXXXXXZJ
13.8
«
There is an acute shortage '5f de-
..................... ..................
13-9
Yet another area of imbalance is in the
h
Dental CouncU.
•
population ratio in India has been unsmiSZp™nel. The
nurses are requ.red to work effectively in different ‘
to be .mparted in keeping with the growing r^d
serv.ces w.ll be given renewed attention. “
nurse
3.dvancement of medical sciences and technolor'gy.
areas a"d therefore, speciality training need
qUa,lt3‘IVe 3nd quantitative expansion of
nursing
Ij.IO There is at present no authentic info
professional as a number of then. ™at,On ^dirig the present Stock of registered nnm
Co„„cils for ,efMul O[ : c h'o ;
f “■ ”"»O"i"8 or f„e gone
X
r
Human Resource Development
13-11 There shall be a separate body for determinati
'
or medical
teachers.. Snccial
... Nonage
of Kacte
’
' "'“Wr"'eS !ha" b« Si
ZX.''™
d “"d'—
»f •<■=there is p
specmlisanon 5in!,"
subjects
in which
13.12 Institutes of excellence set up umder Acts nf p r
New Delhi and Post Graduate Institute of Med^EZn^
2
A3-I
InStitUte of Medi«l Sciences
h' C^-digarh would continue to
13.13 Continuing1 n^dTcal ed7c^onfedolfeurtht?3X^
be Imked to attending a prescribed number of CMp28
°f Re?istretion shall -entuallv
» the
.n.pabsence
r«g .he ofstills
of par,medicl, X1 “ , XX'
Pr0Srm“S b= fXd
a medical practitioner.
P
de 3 ba51c first ‘'ne of medical care even
Fees and Resource Mobilisation
and deemed uttiversitie^Thrpe^X X^cha""^*031 m'titUtionS in the Pr,vate sector including univ
9f the MCI Act shall invite further dirqualificmiotfs undeXthe AcT "i"
'3-1/ /
’ '
e"',anCCd 3”d ^ions
// /feefL^—) /It?,
pC
1
14.
HEALTH INSURANCE
14.1
regulars the secZo'e'nsurcfoTwho" '"d’””?' ?d f°r''Sn
;h're wil1
a growing need to
health insuraaoe would I
|v '
"e'd
•
out of the system. While
the-less remilmnrv
7 b CatennS t0 the organised sector and those who have i
paying capacity, none— ...a consumer are
^Itfoed aLgwifo
”
the country’s needs will be
x xxz r, X"- “xx .h-e
14.2
Xps andfoe “aged”-Z “Zb11 7T ‘° e' “PP°'"d by
iusread of esfoblishing „» medieal ceaA would XiZ “
15.
15.1
S““ “
;°V" P“i“'ar'!' ”
™«Sem
““
MEDICAL INDUSTRY
X“Xo xzxxz “zz “,"ipr”- “d ds™“-m"'
devices. This systems militates against rh
no tap, for XX foe dS
d°"'n .Standards for med^al instruments, equipment and
'
„ X" X " aT’ °f
11
to judee whether exemptions Oimhr m h
J1 productlon and tbe cnucality of the products in order
are of life savin* nature This ll
r
SpeClflC et5ulPment. devices and consumables which
the country TheTational D
A h
' ‘0
Wh°le
°f
and vaccines manufactured in
X - » “XXZ
16.
MEDICAL RESEARCH
16.1
the developing as well as th? d°
over
the emergent non commnnirnhi
eSPs":
“ i"
,™Si,iOn' AS
“ —
VS grappIinS Wlth a lnple burden of diseases which beset both
it
cS"?
f fa’S r tardM Of
h a th Care’ 3126 nurrlber of communicable diseases, and
z“bst:; “x?”4 xNewe,; f"8o,Kn- ”d
and .rising demands are puttins health systems
Sen°US C°nCem' SpirallinS costs
yet millions receive inadeainrp
■
Strain* Stiltons are spent on health care annually,
ultimate test of its utility woul 1 nSatI1S ac^ory s?™ces. The basic objective of medical research and the
applicable appropriate rechnoloZ’dlvices andZ” ”ail'‘'’1' k"°"';ho'v in,° sin’Pisr l"”'-“sb '““y
laiea. iechaelogrcai aphreeemea.; Z', “h'e “ch'I a'Jh”5 “"T a"' '°ndi"”S'
l’l“nS ‘h'
in the remotest comers of the country.
h perSOnne1’ and t0 the fronthne health workers,
"
16.2
. • 16.3
toP understand theirsocml/hetth'and2 nmrXZ^^^
that is acceptable to them.
2nd nutritional problems and
P
17
SeCt‘OnS °f
makinS available a health care system
16.4
An atmosphere conducive for research interaction is essential for holisiic development. Biomedical resea
is last becoming cost and expertise intensive with new dcvclcpmciils taking place each day
comprehensive research agenda would be formulated and put into action by pooling the available nalh
resources. Promotion of international collaboration for capacity building of the infrastructure wouldencouraged to create the requisite competencies for the future. A larger funding for R&D based
project proposals as opposed to the present practice of routinely providing lumpsum>eaHts tQ instituti
will be introduced. This will ensure that in the long term projects are related to capacity to del:
results.
.......
I
16.5
For research inputs to feed into' planning for health,'it is crucial to strengthen the research laborato
in the country to undertake research using tools of modern biology. The overall effort would aim at
balanced development ofjaasic clinical and problem-oriented research.
17.
PRIORITIES FOR HEALTH PROMOTION IN THE 2IST CENTURY
17.1
Both the public and private sectors would be made responsible for die promolion of good he illh by pursi
policies and practices that:-*
lay emphasis on the certainty of health to complete well being.
avoid harming the health of other individuals.
protect the environment and ensure sustainable use of resources.
-©Sr
%*-
I
I
I
restrict production and trade in inherently harmful goods and substances'such as tobacco
.armaments, as well as unhealthy marketing practices.
freve I y
Oo
cto.. AL ox-? AL
safeguard both the citizen in the marketplacezand the individual in (he workplace.
i
include equity-focused healthTnpact assessments:.as.an integral part of policy development.
.
.
.
•’•■■I
.
.• •
•
18.
POLICY ON INDIAN SYSTEMS OF MEDICINE AND HOMOEOPATHY
18.1
India has a rich centuries old heritage of traditional, medical and health sciences. The philosophy
Ayurveda and other systems, like Siddha and Yoga are testimony'to ancient tradition on which scientific b'
care was extended to the peopTe.' The ancient medical systems, have a holistic .approach taking into act
all aspects of human health and disease. However, with'the intermingling of cultures; these systems
relegated not only to a secondary status but they were also suppressed.' Yet'it is to the credit of the syst<
that they have survived and have'continued to be practised widely in the country.
18.2
Immediately after Independence.starting with the First Five Year Plan, these systems of medicine recei
a broad policy support and moderate resources. As a result,'a broad infrastructural frame work has b
created for the development and promotion of these systems.
18.3
At present, the country has more than 6 lakh practitioners of the Indian Systems of Medicine
Homoeopathy and around'300 educational institutions producing about 13000 graduates every year. T1
are 21000 dispensaries and 6500 hospitals of Indian Systems of Medicines and Homeopathy! There are
about 9000 pharmacies manufacturing drugs of-ISM&H. Unfortunately, the services of these systems
under-utilised at present.
18.4
The earlier National Health Policy acknowledge the high local acceptance and the respect enjoyed by •
Indian Systems of Medicine and Homoeopathy in the country. The policy expressed the need to inh
IS
I
19.
i
SHORT AND MEDIUM TERM GOALS UNDER THE HEALTH POLICY 1999
19.1
wi"................. — not deny
i
19.2
accc
The goals to be achieved in the short and medium term are
eradication of leprosy, polio, yaws, filariasis and guineaworm
infestation and sustaining the achieve
t Trough proper prevention and detection programmes;
I
reduction in infant mortality to less than 30 per thousand live births.
-
universal immunisation, reduction by half of low
birth weight babies and doubling of the numb^
institutional deliveries;
reduction in maternal mortality to less than 100 per
one hundred thousand live births.
Reduction in annual malarial parasitic index per 1000 cases to 1.5 in 2010 and to 1 in 2015. ■
Cure rate of TB to go up from the present 50% to 85% Ln 2015.
Prevalence of Cataract Blindness to be reduced from 1.4% to 0.80% by 2015.
i
I
establishment of facilities for early diagnosis and treatment of cancer CVD and- hvnerr '
Dtstnct level and at the Community Health Centre level in a phased mannL
hypenenS'0" a
i
capacity development for treatment of mental health and disability at all district headquarters.
3 C°"’P^ised health information netwot
SsLiZve0'3 br°ad baSed diSeaSe
formulation of a special
‘ tpolicy framework
^..vlls for the rational development of human resources and
integration of Indian Systems of Medicine i
--------------- in the overall delivery of health services.
I
i
1
■
ii
J'
r
20
5/8/00 12:45 PM
nal Health Policy
Subject: Re: National Health Policy
Date: Fri, 05 May 2000 15:06:00 +0530
From: prutvish <prutvish@actionaidindia.org>
To: Community Health Cell <sochara@vsnl.com >
Dear Dr. Thelma,
Thank’s for the mail; comments of Datta; and draft NHP document.
I will get hack to you soon.
/
Thanks and warm regards,
Pruthvish
Mk. I^L
P Lj? coe*
c+(
C
c'r<^
V
MHP
cry
to I
C.
KYI
C<~>p
O-U C Vi '
cc Lie cC.
(a C_J. D'cicp-vc
) P^~p
*<
rxj7/c51yo
cs>°
I py ca
e
mis for Draft NHP from Consumer Group
Subject: Suggestions for Draft NHP from Consumer Group
Date: Fri, 05 May 2000 14:27:27 +0530
From: Community Health Cell <sochara@vsnl.com>
To: "K.K. Datta. Dr. Director, NICD" <diniicd@bol.net.ui>. Dr Sujatha Rao <sujatharao@vsnl.com>
CC: "H.Sudarshan, Dr" <vgkk@vsnl.com>
For:
Dr K.K. Datta
Ms Sujatha Rao
cc:
Dr H. Sudarshan
Greetings from CHC!
yi from Community Health Cell
The above mentioned file is being sent to you
Kindly
confirm receipt.
as per instructions of Dr Ravi Narayan. 1 ‘
Thanks & regards,
CHC
Name: Balaji Fax.doc
Type: Winword File (application/msword)
yjBalaji Fax.doc
Encoding: base64
1
dH :
M
jranfcf ■snn}’
Dr. K.K. Datta, FAMS
Director
’A<l“ Rcvf)
Telegram : "COMD1S" Delhi
Direct: 3913148
3971272
3971060
D O No’ "'
C
3971344
3971524
Government of India
3971449
3971326
NATIONAL INSTITUTE OF COMMUNICABLE DISEASES
Fax No. 00-91-11-3922677
(Directorate General of Health Services)
dirnicd@bol.net.in
22, SHAM NATH MARG, DELHI-110054
dirnicd@ nda.vsnl.net.in
10 April 2000
Dear Colleague,
Perhaps you are aware that the Department of Health, Ministry of Health &
Family Welfare has been for some time working on formulating National Health
Policy in view of the major changes that have come up in recent times bringing
changes in demographic profile of the country, epidemiological pattern of the disease
and organizational structure of the health sector.
2.
This is to request you to kindly put your thoughts down which ought to find a
place in the health policy document and can address the needs of the country in the
coming two decades. This is being addressed to you in your personal capacity and,
therefore, please do not hesitate to give any views on the health aspect that you may
feel should be looked into and find place in the policy document. Your views and
thoughts will provide us materials in formulating the policy. I am mentioning some
areas which you may consider. However, you are free to give your views in any
manner you like.
(i) Vertical vs Horizontal Implementation
(iip" Decentralization
(iii) '/Policy for Private Sector
(iv) ^Inadequate Resources and Under-funding
(v) - Quality Control
(vi) /Consumer Protection
(vii) ^Use of Technology
(viii)^ Drugs and Modern Medicine vis-a-vis Traditional Medicine
(ix)^Manpower Planning
3.
I shall be grateful if you could kindly provide an early reply and send your
response/views by 20th April 2000.
With regards,
*
Yours sincerely,
IK
(K.K. Datta)v
Director,
Community Health Cell,
367, Srinivasa Nilaya,
Jakkasandra, 1st Main, 1st Block,
Koramangala, Bangalore - 560 034
Re: Greetings/National Health Policy 2000
Subject:
Greettrngs/Nataonal HeaDtlhi Poflacy 2(D(D)(C)
Dates Mon, 17 Apr 2000 14:58:29 +0530
Firoms Community Health Cell <sochara@vsnl.com>
Tos "Dr. R. S. Murthy" <murthyr@who.int>
Dear Dr Srinivasamurthy,
Greetings from CHC.
It was nice meeting you at the CMH meeting in Delhi even though
our meeting was rushed. Do send us your comments on the
draft NHP sections on disability and mental health. You should send these to:
Ms Sujatha Rao, Jt. Secretary, Ministry of Health & Family Welfare
Nirman Bhavan, New Delhi 110 011
Tel:
3018842
Telefax:
3017723
Email: jssrOmohfw.delhi.nic.in
I shall email all our comments as well, These are now being compiled from all the
contributions/ suggestions received.
Incidentally, Dr K.K.Datta, Director of NICD has also asked for all our comments to
include in the policy document, He is presently
co-ordinating the efforts. The areas they want views on are :
Vertical vs Horizontal Implementation
i)
Decentralization .
ii)
Policy for Private Sector.
iii)
Inadequate Resources and Under funding.
iv)
Quality Control.
v)
Consumer Protection.
vi)
Use of Technology.
vii)
Drugs and Modern Medicine vis-a-vis Traditional Medicine.
viii)
Manpower Planning.
ix)
You could email these to him at
dirnicdQbol.net.in
dirnicd@nda.vsnl.net.in
Keep in touch.
Ravi
Best wishes from all of us for your new assignment.
MY1IW 4:49 PM
1 of 1
a-
Greetings/National Health Policy 2000
Subjects Greetings/National Health Policy 2000
Date: Tue, 11 Apr 2000 14:30:19 +0200
From: "Dr. R. S. Murthy" <murthyr@who.int>
To: <sochara@vsnl.com>
Dear Ravi,
I am extremely sorry that I could not join the working group meeting on the National Health Policy <,as I
had to leave the same afternoon.
I look forward to the report of the deliberations.
I have read the draft document and revised the sections on disability and mental health. I hope to send it to
the MOH at Delhi.
Any idea about when the document will be finalised ?
I am attending a meeting of WHO on MACROECONOMICS and HEALTH at Delhi from 13-17
April,2000. Sudarshan is one of the participants.
Do send me your ideas and suggestions so that I can include in my contribution.
Best wishes,
Srinivasa
ChC .
o
Cx-XT LoAv'C/ V
3
7L-
J
^11.
J /D A
7^X2^)
^ll
?
//
U)
3.imrcdu(^4/11/00 10:20 PM
lof 1
bo
Tece
V
Subject:
Date: Fri, 10 Mar 2000 14:45:45 +0530
From: "R. S. Murthy” <murthy@nimhans.kar.nic.in>
To: ”Ravi Narayan” <sochara@vsnl.com>
Dear Ravi,
I am delighted to receive the document. Draft National Health Policy. I congratulate you for organising this meeting on 15th
March. I will be happy to join the same. I have read through the document and I find that I can make, if desired, a formal 5-10
minutes presentation on 3 issues.
1. What has happened since 1983 National Health Policy.
2. The overall approach of the document and areas for change
3. Comments on the mental health disability, psychosis.
If there is no formal presentation, I can bring up these things in the discussion. If you would like a formal presentation, please let
me know.
With warm regards,
R. Srinivasa Murthy
3/10/00 10:11 PM
1 of 1
(2^
to
FRLHT
Foundation for
Revitalisation of
Local Health Traditions
DS/18/Genl/2000
EMAIL: sochara@vsnl.com
By fax: (080) 552 5372
10 MAR 2000
Dr. Ravi Narayan
Community Health Advisor
Community Health Cell
No.367, Srinivasa Nilaya
Jakkasandra, 1st Main, 1st Block
Koramangala
BANGALORE 560 034
Dear Ravi,
Sub:
Comments on draft Health Policy - CHC ’s decision to send comments within 60
days.
I have looked at the draft Health Policy vis-a-vis the section on ISM. I suggest, in point 18,
an additional paragraph be included related to the ‘oral health traditions’. The para could
read as follows:
“The people’s health culture includes widespread eco-system specific and ethnic
community specific “oral” health traditions. These traditions use over 8000 species of
plants for health care. Local health traditions include herbal healers, bone setters,
traditional birth attendants, visha vaidyas, etc. and are estimated to be over a million in the
villages of India. There is also a several hundred million strong rural household tradition
of home remedies and local knowledge related to food and nutrition.
These oral health traditions need to be recognized and revitalized through suitably
designed programmes as a measure for strengthening public health education and
encouraging self-reliance in primary health care, in rural India. The biological resources
and IPR of local communities also needs to be protectedfrom bio-piracy. This will be one
of the new thrust areas of the National Policy in the ISM sector”
With good wishes,
Sincerely yours,
Darshan Shankar
#50 MSH Layout, 2nd Stage
3rd Main, 2nd Cross Anandnagar
Bangalore 560 024 India.
Phone +91 080 3336909/3434465
Fax +91 0 80 3334167
Email root@frlht.ernet.in
i l*SSu^.
N HF-
h/HP-93
------------------------ -------------------^-■—'
I,II-
3/Cor4cs:«rl5
.•^
► '
i.
• • -~“•m
'' '5» >3lS
■-
•■- -V
'
- 4
■
■■
■
U)a H €£-v -i’
.•
. / ;•'•
/ >*-
*>Ti 7 «
ri
t? ■>
■' «•' «4; u>
•
. e
: rl 1
-' .••’.’*•
*£<&*
■■■■<■
>9r?’’5-,g'.i>:’i>r-
?<■
-
B-.-iSi'-'i-'
'4 *< '
"•'^R'..
i w‘ ■■■. -.^’' ■ '*•■^1^
,''^
■:
(♦iS
t
c
»».
®y'xc r?
h» ■.:■•■• :i
■c7S■. ■
To
Mi :o .-^
uzir^;
J.
,.■.....
.
h.:_.-..J.;:' ■
..
>
•
•i
, .<♦'.'
J:
«■
„
- -
■
•
4
•
,4
: '•- ?.* ■
~
5 ri-At:
r; ».<
iJ''. »
;i
►
<x»-■•1
•^O-VSL&T
r: -
i
■ ^f>4 - z»j
.-.j,
.* •- -r, - 5*;‘.«* •*» ‘
X-,
"‘'7 .
Wj5TO«/CjA L.
'
—“
■
■■'
..... ....j >:■.
noyj j£2.S
» MoSPiTft t_ 3ft
* Phc. 4e <4eeKr4
•'Y
* Pe/7e^^a^^-y /
k/^Clo H£. S S
u.ro.f <3s=-’-,?
.X. >.'■'
r*
I
MHR -G3
<<• cwotce^s^s
//??PAoPC«E5
• UMire^sPL
PRoviSio»i *>F
•lE-DOCE
; iMTe«.«roTe
P»sp<»aiT«es»fDiFrat
euvinu
HEALTH
CDUE
• ozzs^Hnwi.
PPX>ex»AC>4f$> r©
r/t^ ffJniC IDO CMI
• PfiACHAlfAr*»J
- OffCi/JTltAUSft-T.O*
• OE^otOTiO*^ DF
PuTMOtt.^’
• R.E OA&APisATtau
c>P Hea cr n rreirtcft
seevtcs^
> ti Et-F>sr it utru/e r
• ^M9Tio#J5WiP To
DFV£io^iJT
>4t5»
• RE^rftocroP-e
-£i<L£.lCMUTO*-£
— PboO PIKOOU^rtON
— cost
— «O«At p/*v
— EDOcAriont&DC
- p»anc«P«Ti»H
— a.esut.rs
—• MOUSfMl
-u)flr£t SDPP^
SArtiTA'Tt'fM CTr
• PffnoPAi Dre. Pou^tEi I
UMTH*I CoH5rr EA>MT I
•'DPw&s/p^px-MocFufK k op pAveerv/iL'-ireaaejj
(^ocieyO
■'• ' MEoi P ■
I
CivteSactsr? ■
3oo»c>£»R-y
5. N£t^
40
PoirtT
’
j
PftO SfiftriME
^Pzr sicrot A
$
•
4 ‘
j—iP--r..-.—■ »>^<
*
S/STEKi OP
MEO lC»*»f
W^OlTW #r**4A4CeS
i IMPACT OP ECO*’
PO’.i C i E.i>
'"•>SU*AM€T"
•P«ERM8iS
—
£ a* * x
• ^sroeicAL
HfAlTw
impact
©MfilYSlS
•W/o« »Ty
• SoAtS ------
\ boo
I
u£
1
SRlVASTAvR
REPORT
>4.<
. .
I
ja
4* ,.3T«v'CTpAy:*<.
»*«•»'« 4|W*J«««»<'»-W -4
3-O-PoiHT ....
<
PRoSRfl^^
'
17
■
- — -- irj-a.imwiijn TiTTOMKHiTf U'l"^'1^^’’
?■':, Z ■
.S A
1 • Tno/A siGAiRTogy
7© X^X-MA ato
(ipn^
r /< -■'^ \
/“
* <CSS«-,Crt/R.
'.
J
■*
if
PociTtC^
i
__ 11
.*-■
.«. r'\
»u ■
•$
, U'g?
>
.,
POPUU5T
'
;
.
.
••"*i'*■??«•' -
HFAUTH Fo^ PIL
RZPofZT (IWH')
4•
f'"‘
^,.7 :r: :.-.'
D£
■
i
'‘:>/
A A;
/
c
4?T*>
r,-—~.-»»»*,,***^*fc'
r ;
■•'y^4
•:
•T'
r—-
--------------
w
COflUiT^N'
RoluTj^S
IpftbicM A-V
i rJ£?r?Ti r <■?? jz
C6R
3 5-7 —^2.7-i
CDA
;j.^
(oS
TI
L£(f) 56 t«
4/
rtfllAAffi
A3
(”> S'S-k
» inriUNl^ATioH 'T
• Ke<T«L.JTy
^AT£
27-n
SCG-R^
TT-3o]k
,O Pt -
riCCi/i
«3
- S 3 4>
FEZ- rariC y
L i Fe.
3^-7 —2*
• Mg.rvjo**
/jvf
> /^Qi
cAPAC <7y j
O
;JZ.
o
bet. -uw /5 -0 p T .
u&p «.o5y 4
• Cf)rpij^=)cr
X Su -MOMJS’^-S /*2©ii®AW5
*~Y^
■—p
(Xjo-^ tt^aCuu-'-J h.iJcl'’^-' -.
S ra tY
d
■
~
<■
«-«-.
YY
^H-
I O2> L ■^r(
9Ao<fOxt-u.
5
C IxCvLt uw^-wx-J^-n
J
Xjc.>y^\j^
c*-j~
J^crCxhrYs
•—
l^r
l3c<”"'
y yv
'"P^C^C-C^
C-£Yvlv.ek
Xe^jY^V
y~
^|
i / ^wpXzy §^>€^c\C^-(^.
CAS'VvS'<A-Y4-r^'<' I
J
»
"T-e tc Cevv^ye vi-XaX^
oM 6 s >
XV^\srvv-<IcrLtc'G--<y
bvtv^ Y-
Xtx
'Y'CcVia.YiXa oi
z^> (^vvVC^v^Pc^p-u^j
&VcX<5pVv^M<
r-^
^(LJ2^-)
(tZ^vvtU^'^Yx
*^-•'j£'Alrvx
~ <^v>^'-'
^-v-v^'e'
4- tV^__ 'tUlL, WvccYc-^
<
--tcsi
GxKc-xo
| s^l1 Co
cY C^'c">^3
VSuL
(vn \fo (
Clee x vv^f-
6evvy> ^a_L d
t_
[ fx ^k^vU <L,
\YV
4o-^ AC ^11CY
OcAc^v;
JjUQ^\-
Y v^ ■>
T
0
J>
( e. i-Z
Y
CL'Ca^Ht'C'^
[ e^-cX^-v 't~«7v' V^''V^
1>c’
ox
’
CtrlU^ .
b(^ ox.
-
p-ex^^
'C^^^k'^L'rV7
V?-vl
Ve^X)iV^
f(-i «V,-C- .
V\^_c_
/
Cbvvv
(jZx^
/ X<KR^;
4 Y’^'ZV
/
r
>
/VaM^
Ye
p'C.E^
Y
^kv
Cci
KhH
[rC)^
c^-
pX^Y ^YC\y\.M
Le^t-
‘°^vwi •
c YX Y I
M
^yuaxv^ <
\
1
©iwX-' >y
c<x^
L' .
11
c-
/Xe ^uV?l' ,.
^H/’K
I Xu •• ' •
, j kALv-Z -
■"p.G n
f2„.,i^rQC.
^ -.
-^,^(c
’C'»tLv
c eYAAG A ^XC'Jo - >
^Cl,LCvvV»'_ gVC*-
|
■
'
i.cv<Copvv^^
I C*D k_ 1^ CC
-5 gg2*
(c W\-€. va_ I'Cx/k-u.^-)
5
<ga^vc4<
^l~
‘
CC'V^L-
(C (zVX/«91 Y\ r<
&•*>-
-kd^vvy'
p^C^C-O
V> \v >v<fcrG’<x'CcA
.
o.
/Yc^k-c-^
(</j2_
?
G^t t
0V
C’^-Cvivc V
^.^C-Y ^pe<.Co— J i U
GjvuS-LvlIr-*^
l/UCcvy?
u.<
*’
•—(~c^y
,
r |cHZk_C-M i-TB^^-2-
/
c. A, x-v- '-^—
-p-^>Sv\’zAA VYp~
z> \-c\->U
7
s
( <i_^J-U>-£-v-i !
■€ v<\x~.
4^ Ig^c- 'XLk vaa^cYc-
( C G'-C
QAsXfi^^^.^VvvvvAC o->vcr^
7
C_^ hr^e)
4x?
^_L<
/Cgjt^V
c^-U
\yvt
Co"'AZ'
CU-9€. .
Ct
cv^xc
/tC^
JXg—Z
'
VSnL <5r
VA
4c
v
^-(bc’S Sx
o
(n \>o I
cte-e-i Wxd-
’
■
■■
L-
^J"(CvxA
71. Ge- -i A A'
-sw«-3“ Acsn?
""T “
p„ tvVvV^v^
b(^]- °r
0^. J>
CY
47, t-'c^Cv^-Ur-v?
X<
T
i.
Cq'^\- ■
J
4
1
\/ *< c
KTcrcek^^^
C^J £
:A«.c-
CX'—
^pz-^^Vw
n <1 c_t
(
1<Y v'
tTclcU
C>v—
7T:
' ^-v A
c^i-hrt
IN"
y'V'Uiw'^S
px < e ds-Gc-
yficL
v<jz
bxk b /f>^^
w
o
I. CgjH
d
c\
(b^vCbG
G)7
c^-
^Sc ss>e
I fx^Ro-^-
\lI)
4^^
"7
V'-
'N-
-c
e-¥-ClLv'^>
:A
c iG
u
f-)
Cxliv - '- ’
.0
L’c
,
.( <•/ ! A <^ Vv>
v <■<>■<■ I
A
Ac 05-^
^x-CIWvS
J
•
7' ,-^7 iti
-b-7 .G
PCvi*<
G ) V < -
f -Aw
j \v> - Uv‘|'
. vy
/
I'C
(.,•■•> tv
I
<. t.
I r w
cx..,
z; --3
/7 r
Y
a4
/•
M H P6'VL V •'C-O^c-'rC-
__ t-t-C-Q kcr^'Cr
3________
f^p^fY'
P—
— H
IC 53 /£-/ GMiZ. t4 FP) fiipc*4'
t <^-7c>/'e>>-ty
Pb>
^Vc
a4hp gg__
-zrp-p^-p§^ pr ~
P}lrT)c--f}hc.
— Lory/i.^^_____
dt 7.0 p
C. <F^Tf—>
/7uOtfr CT^J
"ZZ I
fr&^p K C>^~^-^~P~Xi^--'i - - C—uAS
(jf tp^-'Uzp) VCJ'S'-y fT&
r
Pr^G- /■/p O
— 337 -^^7
Pl-C ^>€X_-^.
r/^C / o 5 ■—7 (______
CDP — //'<7 —^7
^-Tn 6>7j2-a ~Y py
b'l.Cs-f PL\.
^'8
Q. 56
5^__________=
. =.^
L. £/<z-^ ■& i--c
7
f^l C-1 Y’^Y'LG
P L^~)
>w.
------- 6^/ 2^
2-
f3 GGr —P
Lcv^e.
FT- 9^
^37t
pPT — 7o7
r-v
~n
-------------------------------- ^Qezy^^-'-/€>e^B
_ Z^e^'o
g
^>-) ^Xx. oax-jGX-^^o Cc-pxc ^-^-i
57
c<_^-^yi2-^> /
K^pjp/^
p"
)
cjt. cp PPp-^
uv~>
14-c^y y
f l—\.olo^-C.
L^-'
^n-uLu^x,
Cryl^c: !<■
If
CZ^CZ^P) ( P
2"
r^/ix Xv^hxmc-1 /7^^v c—■
J Pl /{' I
sXS^x^L cP
7
- -
,. — /s>^-*-v^OO
KifarCfyi'?
l
p
^L^ctbjz^o [i-^b<Yy\
u, "
pSpch </
L^c.
h-lPfts-
Cc.
-----------------
ck__a
c^A-^C
4?tx.cA>c? i-Oa I C i b>
pyG,J\j^t Lppl^ ■''~>t' (^<Cy-)^>
m&^-)
C5p7kb->n ol
u-
J
( <5^^
1
p(^->
t CaL^ aP
—^75
A>7cUcr» C^a
pc.
w»-c^d
A-^Sc
T^- cP
~PPoP '—pP
t '"
•Y'
rCZ-*-^
P'^Spi <U2_z-U^
cP-tZ-'
pb, Pr^c^i bf He- pqp
(c.Gi^ cj C^c
¥
(^ ^>r,|/ (2
fe.Ac^e^rij
bXzxi^l -p-yt
_____
skXg
rSo
^-J j/L-C-X> O«r->C2P
Pnzn
[-^-pc
xg--o ATo Lo
Ak^uK
I^Ck--^ «Jo^L-j tz? p\c^i,
X)O>Vg^G..I
|
G^-^
■^crrf
f~-e-o kb> /T,
C^J
L CS^~)
|
Ad'
^/r^ c Pt-
-
_______ l-)cc)k ge-yvi Ce c^yVe^X-ixy
i
/Z7O>Q yeo^o-^ v^/a^ex^
/zfe-^Len.^ i’^-'^c^/) k
/^C|/L
^-^C-
14^
<^i>L
/--rc^c^
________ <r /X-^n
^>n___
'•4 .' )
. ■'■■ . u
<^tfj vVo-cl ^€
■e
~U^cl/ L~J
-----
•7^
—
-
_j2^Cp.
^ALtAP^rics^-)
«5
&^e jzyc^£-
—
_ _______ (TS^X^uZIz C-^i- —
---- '~X^)
y t^VC^-X7
_________
S'^A-e.
tk>
_____________
—----------
T
L
ml t^C^- C^'^y
/L-j-rruz^)^2^
5
L^fk^- Cker-^^hv't-^-^-
P,
^-n^eg^
f’H-c____
Z^vn hva I <^ ltP>p>^->^ | Cf^ -tp
■ —_
"
' fo Lk-i’C-cl^zt
Z? c^c&A^m' tsn
X2o,
„;p^yr»3^ae^^
—5
u^in.
^wA<r-n. y^<j-YCzvv>xe--
>7 kw-A^ I I
q
epfQ^=Aj2^
...
i>~t^tX£, •
L^e-cl/^^ <^c Vl.C”->
&} ^C~) C^Oe^>e"Ji
►cs^L i
t^1 rTVa-mA
^■(^Ooc^-
F^-c-T
c g>
I
U^-IW
1
A
>c
Mt»v» m
-
l/Ci
bCt'C
tl
e’
9—
K
£ l^-A.
rz
^>1^
Jg
et^C
M
C <=0
__ ^Xx-<^2u*===^—o-
Kj.
c
v /-g^x^ue^,______
/^gtcLi- yf)j>) l<js-'k^
I
Zh
?7*g
(P 14- C | P IX
/
_d
\
-)^-X-P-
7<Sr<ro <J —
—11^=^/Oi /3
fS
Avz^v -L
*--o
E
7
cU.' 7 f
'TK^tcrZ^T“Y
■C^ldL-hi
n
Cr
5^
A-^^ok:
)
L
^pcs'i'oLs
l(A^"h^
L
2. ,
<* /><</ ??£2X>
/?C-<
/v-Cc J
^Lo^ll S
~T
^Q. Ieye
b^r
3.
b
L^p
i4-C
F’<^>
G^c^f
1 f
lb.
---------- -----
T—H
^3zSAx^
p-Hp
X
r■
i—
H—"
H Z7 - ^5
I &
>xK
i^n
j2_
C-<~. /
1—J2rll f^.cfix^/tl
Prt^^ IJeciL
6
v<
j
I
2.
p#-c~
■■"'
-----/Tdo-Z /A VZ5Lo—>txs>
^y-\
/^xs ■\6-xi
C^^p>
.£
P>OrxZC>^rL_________________
3
a.f
-/-_»V'e-p
P I ££ 14-
>O Az>A>7/r/<c/'L -
po/hc^c-
<a
------
"P (^oy^JZ^yZ^ Cjsvirt.)
____ ^7 !/k> s~, VtcpJ <^-
C- I $*•ple^
'Z^ I I ?. g- PxL/oTix
fac-^,Ce-<^~n
f
/Ze^/Z^L
I
‘j^h^Z^yKc, h>
Ch-cj ck
Vf^l-VL
6. P/TT^
f^-r-l^
5
"XV .'A_k^_^-<>->K
p/c> /vxv<>(_£_ pd-rc-c^y
iu^L
______ (^ry-'Eir' ^JL^-f C- fa. cr^-f C^y^cpZf
^r ^c-j hev h
■ 4J^
1
-(3^
-------- ______________
Tvi/p^u/^7/J !
pyX' cJjl_
cvx^
Az2x?ikL 'dJ^t_ I ^25 li~J^J9 ■
COvC
I Ajgcl 4 ce?^-
/o
27^71
61 C^-7 cLv^^^'-v K cj
f\/u.
is-?
^--^vo
-s'
c^^-'^V’—
Vfa-\l • \
-v—^-K
H gtx~>
PD ?7 / j^'tS. S / $
z
My
L\
li
C-hc.
vi
<
p C^<^-uScLa-C^
✓o ^enr^-e g^lelo^
GHQ
/2
yffjc—c^c/1 \
4>Jz>/^ ^vy^?1j
Jf5 cdfejr-Z^-CAt^l I
£.
, P^t? Xc c if-<^
Z,
om ct. I
i£4
V2>|
czz-e-t-'-jy
| kL<^p I d p '■'b) C l^Qc"yZ-o/j
z'
~>^<!>p ^-rd V
La^c .I
<Sy) c
a
7B
^Y-c^l L ~
‘-'v-j
[^ cL?
*Sc £• <ere V (£L.\C~
—psk^^^c
#£V
rK
jr\. C4--J cy
1<^ ~i
=^zj——_^Z_^22_±i|_ I 'Sic
Ut^__L
<.
r^/^LCoKt^
S1-*-K>»gA.lt o>• y
--/^Z^TTL
zJl
b/^-i cl
/^(^y^XcPLCy. c& 7 4-^-6
pXjKrvbvc
fa 6»-y c (
-Z2»^>>o/*£«e4Lt
l)^e jA. !
ecfix<X-C^-A
)4l5V) C GT>—'1'^1
i/k C6,p>>i^/7
Gx^eZf^j(^i
/^6 d^.c c: (
Civpe^c <■
F
<77
y7U> 17s <^-y> &kn
/-
I
2
Hee? tj^Z *774^47^ ^-r-P’
H>^tAy I4cy v
fl
/^ /-4c ^A^~Z- Iwo—
/xfc I'Vfjy^ck fij-y ZL , A-^
-------
Pyv^
V
cI
I
_____ /rux^o^j c-y Zzk^ /Xg>
U^f-p
Lu^O k
hU 'll
G
'"-H' < v ) &>&
Xa-^
(f7^ 7r/h 3gr/zjv\|
et^. je i^,
A^6<x^l^A^
^^pVgCc
(G^I /
\
V^TlZ^xU^
I
[ /? ZZ-c- «=>
i^Cfr^g*ptx^j
Tt
SSSi
G>*--'jt
tV? kczy-,er|
-
-
AZS=C^
—J
Pe ^_
ie<^l^'
^«=
Lj^ .
^.p , jM c-W
C^-ygc.
! f^>l iy &
|
j
v^ f'en.
6n^Z-^V
4^1
Qc^ilij
■'^7
i
__
l-^gop
f i^eiS~r^-LY^
|Ll<Mlk<<^<^ 'pz%°
.v.A
^_L=
_d.
Cl^le* l^h^’
^-Z^-ci
J
■ ■n
,z>V
JZevVk'iM
#
1
v^sr^e^f
1^£»^WS P
L
1 2 c> v>
NT MP+-
\<^f^i
e
L
I Lzvop<_r^«^
f?)
/ Ptl^
f)
hy I-
.^1
____________
]
(
Vty^l^cszt^l
c/i^~-£
[skA.
r^~f <^x '<“
— P^bUc
VL-,
V
t-g <
T^C^n-Kc:
pX
C^> fa >\
/ ^V<-/~> c^v^L
(2^kc
p le^o
flT' i^r') r>
^3 ^ -
v 'S
k Ht^S
#
s-4
-<r
7?
pity 10^
c-l/^
pl^ lO-lf,
f IQ (^' H
/3./ 2
n.
pl^ a. 1
It^Js p (-X^e^» I •y^rTZ
Av<>v^-/
I lcrz>y
^=
r^>
^r-
^y
f-^ j^,/,
/>^h .
t^F/^
J
2/jr
-------
------'yi^pLz'C P<^cA I
“=T-
^UJ^.
c^ L [
_______________ _
i4^<?t
P&t'CC-^
^Cc
/Sfez Az2 o CIa
Io,
6^
A
£■* )O 'i /-'^e-->
--------------------------
----------------------------------------------------fiVasJ*
P 1^
^lJ-
rt^r£6^l ----- N^k
p
dz
T-
I Gf^JoO
------------ —
-
-
h ffit),' rt'tezj'f a-
p
L<z>^ <3^ ZX
fa
o /3
fol
i'-)
s' y-C r>7 € <c
id
L
ilL—
Mz)p^
p.Lk
Id Ctz^t o.’t
~Prn ^i-c
I
^-^r
) y ^pr^ t'&jg-zn^
^r
icy
n bR c cm
- ------------------ ------------------------------------- ——1
’
L,
'-f
&l^
,xA-
Z
r
7^o
-N^e^
~^t
x. L
t
■j*
lt^
<r
7^
k>
N^l^^yd
I U<~)C£2^ k\---
.&><-&.
J
f^-p^cle
£5yv7?'^>f^>«"
fa. r
pJolL
Me
PU^y
11
^faec^-C er^Pc^d
A C5>-7
fV^CL
k
'kfa
(^C.-^'l C l^c -^
L esg^o I <^57<? JI
-ICTP — ^iTeP
^L^c- H Irk'f ^^20 <^T-< ot^cQJ)
__ -
^Ttrh-'b^
iPfa^Lf ^te-Zfe^L^. Mr
I
LP)
JeZ—
to I <2^5~Z^L
P6
ALL
Ver
7c> h<^ c c
/ frk <^>)
T
/
1^1
de^e'
Ovon^-j
fa^Je—rfa^ I <1—
Z2 t— cA. /
1L_
PLL^fa^ i2o~l t
/■
<-
ZtCc<l
y\r
^w-UeUe
J
Jt
b-<z_
Z^Uy-J^/
P<£Z7 ]/t, f
—_ S^\^.^..-
.y^L^L-
-'f
a>p
rA^.—J^CaS
2^ lx-e/^-o I
7^
/%
•Ar
j
cA
L
.cSLx^
\
C l/l^
6.KaSL
U-
k^rr
r
Ccr-n
x
n^O
SjT
’l
_—UzM-P ■2.
f
Lj
—
-Q ^SZxj
I_
H*Cj-<7
L-<
C2)Ce^--&^ -vtdL
^~l C £^(2-
—
p~&t —
(
/-
i^-t- L/y
l<^- j )'
>f^
1L^ 7
M
e-CH-
pJd-*^ O
^cmZ) ic>l lcQs- Ec
C"
^VX>cb-y’
fl ’
On c ( <^C~o
p! ■&
?
/A<v H/f)^
IS^ „A^y,/ay^ ur--^
p-
Con )-*>/
Zx?
IcFD
H£
O-lA-C-j
t— '
7/
V^xkcd
PC i
£
Aj <>
~^->-^ f
f
y^-
.o>
'S
c
V
5
^\J Lr l^<. (
Cr^
-».£^
loA
Lo^p-
i i .
*>:/u<s~O Lb>
(/^<s^-v C In.
CA-'vxlc-
Hn.v $-
L>
( MyV4
4
-£
p_c
—
. r
$1
______ J/C---- f----------------------- -Teyp A >
(~^7.C
^1 \_Jc_znz^-Ap
J
S><^c/g Cry? (o
t~^2^ id I
l-Zm^ ll/L \
gC
__
I
tL^
_____ i
1^4 t . C Ln
4L<xx- ^HP-^3
—7) N IftP^
/^x PyP y 6^/ <X^ LLjl
—±——
/O'L£
I c> 1 o
‘oef <s( (PC^->
H^gL
£^^-7 t Z- /
pl
l^Lz^ld )4&c(
4.
?G>>c Jot.t^Lu A-es-1
n n__
rX/v—
]-—
dS fk^cP^-
7<;ten“h<>->
f^nhrh-/=/-
Pi le>V'
Si
I
Pc^^^nh_
“Txfpr-
•------ - ,
JP} ~yC^
C cnn
MH-P-^0!
L c^C^L^-^C
V S <Sc?<_^eelA4
G^-r^n
P>2^<
Plo^
— ryc>y
i
r^tc. I c>/1
i
<^x
-Mg>
lcfi/2
A
pf&dL. Cc )c^-y^c(^ >
IkrcrC fP
---
~' ~l^nv?>)A^
—
'7 7Ce.^k^
h<^k
-■■■ JiRQ
faeb-fLcj)
Ir cLx-< Ce^i
r^^z^-c^ciz-^.
)
TH
kb
^Ly
Pir c-JLj2^-
» L<_o U <^-
X
-----^yyY/'
“".
ru^
</
_
TTl-Co
—=feCTX,
L
/^v_e.
fo t, fT^hrM^^A
j
i
5"
J
4
—“=—$> C*1 ■a^v,<Cj,—-i
r--- —Alb—
^C\ O^nOl
iCeZ'cx-c-e /r^>
zVo/^
4
4
l
*7 o
7^
7 ^'?X
<SVQ ^p/ C.
I G$~>cy» V. y
u
^r
r3>x*&
Ca5Ao
<7
P^l-e
pO'vZ-.c ^T
---------- =
kle-t^e^r^
1-h^kcJn T^rzj?
T
/No
-S[
fixsa i-'
Sk
e
V (o
(p-ncsy-
P^I^Z. H^P/<
TTvcXyn.
fP.Ap(>~riV\. —
C t^\
<-^
C^^z-7-> cx^--xs=yC)'
^Pcr-^?U. I cPl cn9
7
r~^Ls2^^) k c}
i
l^'t d'Zn
Pc^Lsync-jy
V■
‘Sp\<=^-)Pc~Y'
FPll^
ifC' c
^5 AC-
P/^c^
<Cc?y-<--2
X - /2^
<7
C_/D 1—
>~tx_A^ L<2^p/1
jc.
^ijsw-Aits.
O~^lr
A^<-Xu-O-7>
)
^<2^
S
7^2-O<
t^UlP-^-^
ik -
■
< YVU^YV<^C^U'^^
b
oAa>&u/>v\x>^’
X •
^u\/^
tjia^
^AeA/lfk
tv
/7<S-rH'W^ ’ _ T^vma^C-
v^e
<^0
<X
Lu
Yf6__ 'kn^>>
w4j^
'W^A
£-9^—&ioC(
^yv^h/
-b
4kt
J^V ^Cy
^xWv^
^vwjczy
^prvdjO^
!
•__ ivQ«.
^*c!ai
if
__ WKaI"
v\>-Uu»v>Zs’
jiN ?ybv^
/yk£^u4-
^€-
^iSKexzj
Cjj^cJlJC^ I } »I (a
z^c^K^i^Cvj
,,
Ca^i)
jt .
<Jg,
pH^f
^sv^v^1^.
’
.IL
_ IZZ^ln^X^u?— ziszd—f>£i/F_-35_
af
hkylh
<*57-)
/5
Q^7r>-C A^T^'^3
£^-t,c ee^^e^-1
__ L. Th-. C^ r1- Fr&n C'CZz-r
c.^
Chr.
>
(jJemlfc rtc^c^^u^Yr c=i/h^.
^^e^ll^rCcsx^
DyTZ).^
------------ ^/v^C.
xf I4^uk $^7ee^.
Ik.
ti
^-e^i D-e^l sp
'mccec^ ,
3
P~*^> f^L<:gxr2_
(J o
e -^-r^ ^^YrO__Prhc^ V^.
c
O r~iCho[<S~<Z ^i
fy^ /7- ^MugLov^»Aoo t.
K>C
r^cja- i>7
y^-u ty
g.
I
MC-l-f , r/^o , re^*cz> e/v
^Cj l4co(VL
V^r- 7Z.
f&j}
—d^-gL_
~< /"Ig^nbeA /^x^rTe)/^ P^-kLe- 72>r>l-<-_ ^k^~.
LSI
U^^.
TZiT''
C^i , /^<7g<y^^2
i^bl.c. Oe^lL foU-
)
lKJh_
<</<y 6^-^-^L) MaLi
>c, hv-e/it- c
?5^a^
?'''(&». a f^/y~
. fS^x ^c ixi^L.
l4^-£>tfl^ , J)
fr-
A^r- C<g- /A r t/^-t^
c5
/Zi tp^~)
/% I cSerd F^><^--> JC
j
Z<r-p/c J^srCfL- l^-> /4-e*
<==^C^
A. c:l
CH
Gp-cV
-------^K..^
9- Z-?.s P^,A,
cs-r \L_—
<pV^
/2^k
J^z-i—z2ctJi
^^S-O^>C7X--> i)oil^
■<d
C-CSYpcJ^<-
-<'
________<^<ar^ <~
7s/ cy^«.Ko~>~? tQ?)^
dh
zyug^n p
l^rzrY^^2__
0/7 <cy-^z>^^g^K .
<5yv^>t^ Z/e* z~ t4L
YLifS^y h
1^
^rr fi^iTrl
A^^on-yry-^-^r^
A.
^L
(^pe^Kc
IL lL
tg-Acy*i
/
fS-
lC
o
t CCU\
L<~)C
*<*>1 ^1<5) -g-—1 C-ll
Q^-n,
—
(
£'&'■■■
Hz rt^
^t^l.
6^7/(XCA-?
---------- ^_ke^<?
-X ^.sA
J
y -^2 D<—‘>
f CryC
fi_fr<°o3 czx^
ix
4 <—
rC (’dM ^e. ,
r~Ce cttre<-f £dj-^c^K<s^
( C_ L-«n i r rJ F~? i^rAc c.
Ik. fjr' *77, ^T>^_/2vVVoA
(S
!5~gg~»r<g'Cj<—?
kkb oh» —^y L>^ia k
C/g7^ z
/
?
k'' kke> rt(^h
-y
Ske^Ltkh- <-^i
i—7
iz / rxv-^.
^7 A
kyy f^CactXCLcl
LaA<>>
>
ZA
n
_______
/k^\^L I/ d\ CJry
C^ry pak
kt-li S
e-- \!k
3)^ /Zr->y\ r
c
.,/j4e^.fl!k
(^3^-hkc-
//<»>■» J/L , JXx<gt<_A_o/^Y( Ik* r!i/t
D=^L
&
iLkL
k)-r\ ^'vo-€-<>-
_ ____________ ___
C
—
) kcoA' %2e s-*->T. <rL<^L^-<y
^hf^> crc^
Q Lt? fi s
<J
/-l-^^ljk <^4 I 3
(krr^^
-/a n-v s o. g</L
I
rl-y
■ f'k
I c<^
lk^c.lVL OJl, 3>cytjcJc^ __ rt~i" ‘k 'I'
te S^C^ZoL—
I
V
>
t—dr—>
_____(rr^-c^i/R cz^.[l t F5
--------- (2__Cg^^^<us
______ __ ___________________
2jZ—Za2-»- /^/-^-y—>A
7 k&d-i
&
f
i err? c
L
^U^st.
^tx oo
J
(-g| &xy^____________
o
(^F^L\^ n_^-dLjLc^
J
j2.<^LX
&
^L.
c
f^^o-t^-.c>
r~te-Z7k ( Jf^aVL f f^CVLC'cl
^vp
<^-iC^.
Cg-
2^
^e-l<sv<L
R-x- k)U c
fe^ukA
©
f^)pe^->cL<. ^ X
/7ve^ ifTritsJ^^-^i----------------—
Gzrrry^c^i/i>
Z?
€<f
-gl
<^->
I'fP- ft
ureu^>
tPrz-fp)
cz^nn cn-x-^-?
hj’^t^i 'r sJ h>£* rlc
JL^.
5:
Icxo./L
JL^rzyo
tizLx.c.
------
c
A^
^x^ni^Yorx^ ..C13J^)...^—lk
u
FYU
ICm(L-
U 4 k/ok p^tiYu ,•9 ^5/. 2^
o
£^^A
f^>^r5Lx i/Zon <
On rt-e-
^[t
/l^
______ <cyx7/^ y/Ca^Lc^ egf
HP-^
Pl#-
Ag.----------
p- ee^n>
,/Z:
/ i_
h
L(-^
be
PvCvcJP’Zeke*'-* c^-»ri
ZX >8/0
L(
('Z'-/’)
—
S'd ^Li
is7> YLp . ~
AAsaYL^ZoA
-g^ZvrJ^) rJt
Qoh
s
if /l&
■
k^L
-j
^=^2
L
T
mollpa'*-
CL.K
rfe p^r<fo(p,
yc
YL^ ~t^Z ^~J .f a£Kt
YU.
z7
C Y
U-
C-OS
^21£r2 /
.Yri.. 11 Yy Vga ^e
l
y
P'>4pf> rYe^> *^7 '
5
7
4^2
L
r~1 /rlcnt c_ ->
A^eo
Z^^<7CTc4
Lr7 (
csydLtx
'PYL^AL.LJlC^^SYI
A.
A-
l/<^ << C
& L.^,
7^ /Aj±P-^__k ^..^h^.
YLe
XJ
a^JL
YI^p.
k±
Pi
^^A-^cJKsrSr^
A
re^^
,
hjzdiL^sA^^jAjZj^ l^\ yatio rx^O.
T'^S-D — SCGr-^j<7o
*0^
"TT-
y-L
fDPT
y tLjp^
r>v'^*vg<-^>zX*,^-€
Kj^p^f^-j ^^a-T <z Kicr^
zt^xgLut n crr~>
> ‘/
C-k'
tS)
/L/^7
or"* >
rX^xZt
t>
c.L^K.eL^cf
^csnL'-tn
5
< -<ryr^e^
2J:
Z^-€- Zue^^
<Z^-> gt ^Z^-xIcLtl^--) 2)
Z/-~//^-g^ <z^x> /'tj-nti^x^xr
'
/IATr m
^«O^> Z^w——*■'■»/
o> (^P> {j^^-t> -
ft-G-- Zv t-pt-^
"y
i/-G^.
p^-^hkcz^y
-QacL^ 3//o kic^e occo»^>') J
fC^t
C-^ '/>n My
Ag A OO
p^hL^fjo.
Ly 6?-5?* Ag^ C^CCj^kP)
fL (2- A<^A ygk^e>o
s.
X^€L'
m czrc> i r5.
/•2>l
<S^T-<
OX?
f'prP fe-eh+Z'G. -t^.. /L^. lA ^Pz.&.^..■.. A-oO-fert"
t- l'\$'7 <- o
thJ
o^MLgjkx—
L<?-
—rt^^lk\'i2=J
*______ _______ _j
<a
(?<1
ot
X-g^x^c^P
Ys'") Yl^
oj
xjf /a-^xx
O5iQ Az? C-Cz?
4.
uk
^T7^__
^ZT<4g<A.CCj ,
(,C,
rtf
rl
<Z2^
St >n k
j^^jyin.
a
(^n^i /Lt
2L
—(yr
l^-^i y
2^.
/.
<r>icP
_.
fYi ryz?
Zl^-C AV^t /l cry?
-7
Yk^_____
Os ^^7
D^
A <g> A>g>-
V
4^-A<2 CrX~L Q-,'u
^ir'?^Y) k&4
^t>ll»~J} Yl
f^y:
Al
r>X4^x^7 A-gv?
^>vO
-^f^-
y
to-) Y^ - 5A
^7,g^
er^YisncJ
T±
fT P
A
/Ou r A Y^ cJ^o)
a
>^< g-
ic^y
3.
I
/2x^k— Jj£
r^ ft#- p&f>
kb
j C- /( ffrQ
dL
^=> r/^
Cf , C'py. c i Lc^pz^ b-^pp t^oc.
<yi_/7>/v flk-, >GO/?-
/V/7
—
vuoi^y^
r-C
(-> ve^^ea /
\ kL?_
frr.L
'f-f rSS*
h-Zkclfin
c? £?
7-
rU
IcJicm.
1c
V,
7L
>c (
Yl^l
j^HP-^n.
/U ><b<z^c4 -/2>. /yT-ecCs-.GC.—i
^JZ^S^L-CjZ.
&
==—
X <'y) h-^v r~ 5*^
4' <7'
li^ (2^
)^ /^~y7
—"yc
Xe
^P^Y^C-Ay^eKor’}
lx
Zvx2^-<^ /Z>
xasx/Iva^x
/<s, K.m’'-)
Xj£--
J> ^^-7 <2)
->
gy9s*_______
e^£y
z>.
.%
rJ t-fp -
<?<>■//l<><-</ o> Cy
Z t^'^-'} /u^>-Y) (/^^_
•/
t^JL^
-£^27-
<-/ <?<-/)
rU- .2.0 )
> Ae^ /^ YL-e-v
Z~» oL-»
c^n.
ft o~»
iLe.
.p.
^~i
C'-> L.^ C.(^.
o/^c
o cSf /T^cdiZ^
ry^.
rx^l f5z^7 >i4?X^ zt
Z^- /z?Z’-^>
<,~vn h. ^Lky.
*
4 j.
X ig
/-if^LtV^-
r? ^e^<A
(x
271
Igyorv^nk:!
\_<7> X-g,
C^r~rTy~> /’ww^r
x? c>^ <(
,d I
e^~i <~t?
tC. r
cy^L
j/r^
z/ g
=J/k
^1
C^->yaZLgX
h
Cl
buz-l^L
\S
KLi-hsryP
*.K
fLnJ^ks.------
i-^i l/k P’/flAC^ . 2^^?^ /At^ T— f~l^> cfcAy ^=f M^llk
7/k&_
7p
C-*—}
0
r rZ^
4;^ r^h^cK^c-^
r^h^ cc~i
c^-? / A/p/fve c^ 7\e ZZ
k^k^.
/ 6r
h
£
cruvz c.
/ ^Zc>
D
/7 cz7
c,
JJL^
?
\Yl^
'7c*-'* k-
c/Z\i
h.
C^'i <Jl
c>>oh-<^
cJ
T
At c>>
Z^J e^-y c^i
Ty^sex c
SA~z^g>f ^cu^c^z)^
A^go ^ec^Clt-
A/e^//^>
1^
__ Q-ll TLe..-
L2l
K
c^ ftc ck^c^Ar'.f.
---- x/^>^i—v
lL
A
aLcJte'•si-L^-<
21
A
J
V
^P
<Cl'y(-
>-^7Z^<.
rL
-Z/js.
JE^er>^y s>
^//
(
£/■
4<a
a
<)
/C>
O*"
L^~) I'L-.
ite.
L^
/C^^Lt-XdjS-cJl
L
L<s
<=>^
cyg^-
i
z
/V^y&3
/3
<S-3C (erj^c^
<^.1 x> o
ctl-
cH
cl-vV^
<>-,
/2C
K Co L-
II
?
Ys>
C-^C-V^ Ji
S')
e tc C'
f
tf i9^\
/
dLfc^
O
z^lL
Cr-J^ k
qlL
¥^^5XA 'Czh^L/Z
L
1L
7
k
Lku
J
h.
e^<z
/a
4
>
/^-<ryx<3
k^L^lL^
Z
k
/^
k
^7o L?_
r-n
rM.
>
e.Ajk
<
h^-
ike^Ji
^iS^.
/3<?__
k/z.
tT-
ir
5-7 A^<^>o
c
z ( C5Y~„C he
11^
7^
o_—
J^L
(ZC£L
-Zf
>v_t-< c ls>
ref rVLA^x-yi^-^->^ >
•e.
^f-—-P^^-
<rl
L
.ckudU,
-T^CrX. (? V
cc> J
7C
7
zsL /y
Zf-Q^e.
£
c
/Z
r? ] r...
<^7
^vJ7
-s-
j^~Y~L
r^-
- f'rp fl J?
CCf£?.
brL
Za ky;.
r-r"!^
T~
\,c^U^KLc^
r><^f
£X
Ae.
L
ik^j=
(^~jt -xaJX-/*^r-'jP
let Z~l<^>x"
7
P
___ Z>) Z? ^f
-/qL^
L^k
/s^P—' ___________
A <s-r-> Ay-)
11—A.
I
__
22
/o-ou-jg >ic^^
______ (J^y ef\^
>-P
4
EJ
<&^J.S>
_________________ J
rV^P-^3
o^C<£•/
---- 8
^Csij^y^
^3
£ Wv C^ryycoc^
£-11,
IVnr/cZz?.
Oh
Poll
f
4
Cv
kv-g^b
P-rC|l€VVtJ-} &insA
<^ cU>djj £' fh-Anvv
^fJ^ouya-C-
|) I gwu^
Jt
____
^bg^fA ȣ P
CaIV'Ja t'^-13}
TVUlM__ CaAvl<^X6'P.<i _
j£yy i r/Ct’
4,
FV-f /yih.A/V'CJ A
/tzv
rj~>fY-
M-
/vy>^4^.
______ —---------------------------- ------------------------- —--------------------------------------
3
\l
/ A/n
^3.
<k
r /'
^£Z^££<0-^
krv'
il~c\. <a , r^f
fa
7Aj?
10.
fo 7
b <
p^s^cl
d~E-r
/C k—< /
o t\ J
di J A>x vZ
>VX
S/Z/Z^^-T
An' / < 4 <
/y~y> za<
a
p cy
v\r/ 5 e z
X
r </
4.
Au7> a J
/ Z'?i/Tl
per iy\ r / Ax cZ
C\b y^
/^. //
C^h
CX/X J
lyjs cl I <
I c
_C±J_
OA
y < j Znu/xA ^ttt
All
- P Ko- < A u r-y
^cxAa\/
C$3 A° ■A/1 g
Z|- c/m r J 51 orvf
/
/zA
Ax no tM >x
o^/l
Qy\ c/
y
T
ajs<\ -
C
Lt^
C £ V.I
*T u\rx tcj
Ar-f i\ tx
Cc *v<rv<<rr\
C/X ^'cC'V U’
C ex. o/ c/ < /\ Cl>/^
f ex (/ cb,\J \»»i^
cltfK J KUY\)
C/G r\A> y>< /\ J k <J
-14 r-f
Zt GuV^
__ G <;
kr^h
Cv
<x »v c(
i^Tr' //
r
Ao ((
SKp/{ fa
c^/kc/
___
<
ex ___q/j_X /l»xa/_____
r^/^x/WC^
katt K -
!3. /3l
ur<
/X c/ /rr a /6tV.^\
r-c<
(J!
» C03 dj^(fa,vJ
p ro cl \a cA on
Ai'77/\
CLcyJ^
A^O
/\c/
C o-c/ c/^rxc/v*v\2______
6< /)vxx<rc\ 7y
10 u
C O<(1cLts\ J ^'Y\J
(j f c S Kj. (/
c
Ay
aA.cZ.cr______ _
ex c/zn <n •* T /)r^ A
h'y
G 4y
10
/6
ty<^ ^rA^Xon/
<jr^ d tAod-f
SK^h
p4 k\
J u /rx /
ZW<L<V1 (.i.yy
C/>
IY\ f /7’A
(3
/?-/
>K /Kx
5^Cr/
<5 a
rcc»,cZz
o,^
G
v» r t
'r\ /Ku
a
'j
hr\ c- flex
C C^cl
l c\ cc
0^-j ) —
-
Cc'<V(.-\ c/o
)
£^(2(1 Ac. n
/<//vi r
Ccj
-
.<^.1 l=Le.&. UK Sd3
&
^t/srjp r
lC> ^V1
7Lv-W-^:
TDe. V^- ? !
^=> /
r^Zoyc_^)
y
____ ._____ 1^1
I
X) ^2, 6<42g .iro>/4 />_
:/
.S -
f TTOV^g^yTv_______
Q-rc'^S
(fu ^'£;>cbx
i^£Tr\.l
B lx. -zr^ c<L/0e - <S 6 c> <D 2-7'
tfr 7- BtoKA^/N/
22t,
)^£vrt_____
fiCLr\j Cilcyc '
c^o j 1
A) o7 rO^M I.
o n — p>Url *y\ A
3
Icvyan^
f^P
I
Cx)vvv^>
D* ■ Hcrt+i^v /^rp-c.
jAv^-<j^erV PLL&AJ, XA-^y^'
PIHMWPL P&Pb'L?^ E'c
\,f.
2^^
\ > A;. . <7/7!\ii u^\5
Al
_ C/7 G (177 5? ?)Ct
‘S
■IkA-
__ 0/- A'l K 'S’ v< c/crrJ A<nO
Pro jy /-Z cZ) c
Co<r\ • /T) <</■ ‘Gxxg
^7
Z? ^z-y> Q,
g.
AcZ/Vl S/
£f_
&
I) "G
S. K , <7 krr&lv n
£< D. /-Rs^fU,
7.
f>—C t
M^Al/r \a^
6 4M’
R) V J? A/ / / / (ajCv^ nlACl/7 Va
4 0' /A01^ ^X^-'I
I/
Cs lift
°r(. - 3
<777 Zv^-^1 __
LL/Lr^
I
______ t^t'
X)K ■ £>.
P^ut^v/SH
(Lens-^r^ ’ vAj»a/^-< —
D • 5 *^>
i/JV) f
A-r It
A'S) I
c^,____________
NJo- 3z
Kc^-^- ^>^<)
<3^4kU< - ^bo ool
3.
I
r .
T^i i'S'srb^^j^Qo} ;
—=___ ^aca£--------
3r—^T' >■< -
^tL
lo
U
>0^''^ (<
L2.
rzAdVxc\w^'v\^.
/\
’^rArx -A S
1
fenA^XsA -
Iu
~dsU)-^-lA. Xj-^ -lLikv--jCl-
^AAy
__ fiA
ril 6k4
JLl^g kLqXc
(LWC-
tk
S~ 6 0*1)
V.
I
TI
I vu • • ' '
G>v '“f. K •
-e v X. ) h. A L v/ x
<Y C^c
'%>v(c
q
JWVWf-". ■■ C
C
-
.•
y4 1
"Hl Lc wv»'_ uU"
r-
V^v:
f.ri^^cwj
(cww.
CJ
.-lIG c^C/V *1 C <3p^v \£
I c^d L -p* CC.
bef-o*-
-. jSvJ'Z’
C-Vx_£\,<,> uwrvv'—
vv 11.
f
■
> V-
Pcx.|<-ur^->
C,
cca-t-
(zvw< d
r<
tkL 1^00 *•
X^'vvvcJ-C
pG<CC>
G>vvy?
(_ VA/ WwzfoAcClX- ;.
Acua-C k
Qsv-S
—
CuKtklve V
£pecvc’
|thfCCC H" ■k>vVX,_xX-o-o-Hj>'S
.
-j^Ouxx\rvx V^j"~
SA/l^
CA/Azv-y; —
^€.G.^ A' A"
■ev<w
V S at -
■)
( tf ^UL^-v
T> c 1 e Ge— vsvwvx' ow^cn, J
o
(vn \>£ \ *'£
cte-e-i vxxsk
^"{G-vo
f CUvv^c^^A^
6AZV- 'fh'YZ'
c
Gk >vv^cYVC-'^-'
4q
\y
( <l_fcS—tka-xi )
/
•J At-
,
c_M. b
VuCvxy=
( '€<C.
•
ft>v>y> <''A>
4c
c_.^ hf~e')
y
't'^CA/A
c
.
eTL-V'
r \yxt
e
[ *\
^vJx
^,VAZX^)
„4o« t.™c
sm/-
ct,^e
^c 5ni
/vx-x^L
p.CxW<V^v!
5 (-*yj-
CY
c ■ r-l• v x-<vrL.^7
5-b4
crjS c- VW - Vctlc^U^Us
V «_cIa- c i u^-^-i W'-C. .
C^l~ C^J
"’cte-c
^p.^Vvv
CLsvvv /
4.
4
,
k> c
V>
n-e o«:
c
v7
^TJ'CtcU
xl
-^C-i
Ce^i-Yt
,N
r~v^ W 'Cs
CX^-
is e ’
pxG°^<c
T'
i F\iKc-G U
lz
P'
J1'7
u
---- ^C'S
L^COk'tjC- \yvb^-
V N<'
C- y-Ct Lv -S
(
-c
.
We*
\
}■
f '
^V-C.*Vk c>—
M
H /
'
'
■A. w
\j C'-l
|
5<e‘
6V i
c rl-
v X
' ’r V
')
Cclix-"*
L’C
. t' -< t V
I r v v>
) V V v*-
I'C
CA
c,/ ' A jV&'^VV
... ....... H/JU
?
1 \V » '
‘J
.t,
^>uxvvv^ ,
^'rwy
A.C- >
} '
/1
'>«
r'-Z
issue
• ■■■'•.■ * -. '.J..aV.
<1!tiSSi'-t'.«,<’’■ <--• ■ Si
/'If" "7
b/HR - ©3
k. CW©ttezl6<5
/^PP«OPCR£5
• UM/vejISPL
PPOVISlO** ©P
P£>^|AA.y WfALTW
CAA.C
:
iHr£«.«rATe
P»s
»ti e s/D»prai
euriff«j
• Oy’jER.HAuu
• PA>icwAyArr«»J
flFPgz>AC«f$ To
-©®eeMT»AuSA-'r»&>‘ I
7X. A iAi/F/6 fFDUCMtw
- OeVoLOT»0*J AF
PuTMO«tf«’
• ^^O£SX?>|JSATiC»>
OF HZAtrH 'EltiAcrs
>MX=X/3ST£i>CTu«r
j
i
• PRiMftlSy WEfilTM
Set-VvcEC m©C£
• K£Lfi»T>G^HlP ro
><SE*
OFV^€OPM€‘**’’
-R&je<c.utTu«-F
-^OO FAOOU4TIOH
t
-RUCAt P-^V
• #esrRuc.ruR.F
srsr*’*’
-cosr
- Px»<rnc»P«TiM«
— £POtAr»o»*/SAC
ufiFM*
— WOUSiUC
— ftesoirs
• X9^AoPiei Are
I
$flrJlTAT><»»< ETr
UitTHM CoHST f&AiHT I
Au O>5/PUPAHA<F«n>C^ OA pA*eftTv/4Lctr£e«c»|
-uarEit supp-/
(PotrerO
W rfeoiR
I
€»v»ft3CQtBrz
5. Nf0
io
Too»c»oit.'y
PoiiUT
I
PRdSflRriME
?pzr
sEcrot s1
. .•■«4r<*M*V»
v-w, r^—~* «■
— *. .■ t r I*
Sysr^xS OF
HEOie»Mf
Wealth ^m4O4C?S
oP £eo^»
j^dSLS C i
mff©
lp«£OH8lE
4 .
fit.fi) L
X CiM <•* | cz M TJi.
• Ms roe» cal
OMfiiySis
•PP.102 jry
Hffttrw iMpfier
fi)SA£Mi-ttr^T
i^&5
• 6ofitS ——
i
•.*>
Nhp-w
/ssue
■
- ,
, .
•
SRiVASTAvR
REPORT
G^T«*)
fa
iLo-Po<HT
|Mni.WTrtir~iB(
4$
••■i ffl'rS*;'-U
. • ■ i- • <
...
>-•
■ ■
;'
“ ■ ■
|
?
”
1PKc>
•»■ r;U?
7Vj z.
■ ^z.
> 27^0/A oiGN^^Py
7e fllrtfl flTO
D£G±BfcR7l&M
ICbSA-lCHfi.
WFflCTM Po^- WL-
^epofzr Qw)
y
• PoPOU^T
f
i
•. *
PotiTic^
1
'
v*''
f*
L- iSwixZi^ r :
•'”
■••**-2^'45- ^'>'5
‘
.,^ COA <u-< I
Pol.«ticS
P.. Successes
ib^HriPtS^
i joio—w —wwwb i wi'rt 'X~<r~— <
PL^Gr^ £-
G5tReHsrws)
rinco^t^
CMOUt^*
4
r(o^T«LUy
P^T£
C&fl
33-7
COR
!3-»
Irf Jg.
(05
LE.(P) %•«<
4U-2.
55.
tz-s-
irlriuNlZ.^not^ I
^CG-^4?n TT-3©K
7.7- 4j —> *^’3
Li Pg.
Pt -
3q
rYg&o l>ss -18 3
P£g TGfiC. y
3^-7 —^^2.
* cepAo-syJ
• M£.TkJORK G>F
» STocK of= nJP>NrDK
>t e o < «-A u/ H & ay }* T^X,
/>4Qi 4^*00$ sPPAray /
O J? JA
£>£Z.. u
C P T .
^XL^XJiCATl OH
® cp)rpi/2j=)cr
\ ft'-j
P2©^RAe?»f«
'.:>v
«"•■•* *>V*- '■ ■
• ..'.. •'
I S5u£.
•.a
nIhP-@3
y £>£
•
3.Cor4Ci£®lH5
.
-
■*
. ,.»• j-v. > •. .yCjW
. 5
■•.
• '
•■.-■■'
I
H‘*
■
•u-
xL«>
4 -
to 3 >*i ££.•*» ‘s’
j- '
AjSsS
:■
•*
*■
uF* -f
*
*•*- tv-*
‘•’u?
1
.^.ii {•““j. .U-*> ‘-'A •*.
,’:■*
-
. c.
' •- •
4.
f'*.-
■•
iw-.'.
v.: 'Ur;.
■* i. <.« •'«♦»»•
* ^>SX.C -T ” '•’
• Xz , ■’■I
'.
'M i: ?
T A ri ; «■ ! AY S £>
frr t >’ ■'
.
•t'
•• »
2.;
*
/•■ w ':tJ. ;■., ■^,.
w ’..
»
•Poyg.2T
<** 6«.
. • w 4.-«*7*/
•'
* ’
7 •
z*-?
O j.*^ *
i..^
<*»
u*-
;■••
-
v‘T.4r-r-rf
<k; ■ •<r/ih
B
r*? t*? .Vc-
&
r„
5*^ m ,•-r^? r. ">
* •' $ • *
<*i
—j ?r—. \
•
1
HlSTOfc/C^L.
fl^fluysiS
A
Pouet.P’uL
..... ,. «-, .;:S< ’.•* --<
r-toJZ .EX.S
* Hospital ®«S^o
* PHc /4e^/ccXr4
* QU Ki ro.f
i
L.A€<
•
C.H.C’S response to Dr.K.K.Datta (Director, National Institute of Communicable
Diseases) for views on policy issues for Health Policy document dated 10th April
2000.
1. Vertical Vs Horizontal Implementation.
18
2. Decentralization
Different people understand Decentralization differently.
Delegating the administrative and financial powers to lower levels. The
1.
Decentralization is within the health system. Responsibility and authority
are delegated to lower levels and to the periphery, quicker decisions can
be taken and the problems cab be tackled at the lower levels.
Empowering the people to take decisions and act locally. Here there is
ii.
transfer of political power to the lower levels- from the centre the state to
the district to the Panchayat and ultimately to the Gram Sabha.
Such political and economic Decentralization requires enabling of the
iii.
people, making them competent to discharge their duties and
responsibilities while exercising their authority and privileges, collaboration
with qualified and trained persons (official and non-official) can help in this
process of identifying and prioritization of problems, workingout feasible
plans, their implementation, monitoring and evaluation.
b)e.
fkcV ^ll
3. Policy for Private Sector
ii.
iii.
In Health care Services, the Private Sector is much larger than the Public
Sector. The Private Sector is not homogeneous. There are different
players:
Private, not-for-profit or voluntary sector. The Organizations are motivated
by altruistic or philanthropic motives. They may belong to different groups
and philosophies Gandhian, Marxist, Sarvodaya, Religious and others.
They may be organized as Registered Societies, Trusts or companies.
Private, for-profit sector. Individual practitioners constitute the largest
number. There are nursing homes, private hospitals, and corporate
hospitals. In recent times, the corporate hospitals are dominant. They
provide tertiary care.
There are co-operative hospitals and group practices. They are not very
prominent.
There is need for/a policy of partnership between the private sector and public
sector.
'
The Private Sector needs some regulation to assure quality of care. The ideal is
self-regulation by the institutions and professionals, maintaining appropriate
standards: structure, process and outcome. The Government should be both
renulatorv and far.ilitatorv ZHelnjnq the institutions and nrnfessionals by trainina
,
i
There has to be transparency in all dealings. A process of accreditation helps!
/Pc$T<.c^ fix
T^LjCZ-
--- -------
tx) cJd-^C^~Q
^ppTr^pnrv^^
---------------------------------------------------- y^dSTz'cy
• 4. Inadequate Resources and Under-funding
sTa^ac^
I e Kcx> ? ctccyed^c^*
^c^feKcrr-) ci^n
5. Quality Control
Quality assurance is a must. We have to define appropriate standards of
structure(what we put in or what is available), process (what we do and how we
do it) and the outcome (result), Outcome would include patient satisfaction.
7h_i2^~^ ez>
<^vo)yo
p
czJ7
-x
\}L\
62 veto c$f A-^
6. ConsumerProtection
Major drawbacks in Health Care are as a result of negligence and incompetence.
There is a duty of care which every health professional and health care institution
must adhere toThe Consumer Protection Act is expected to help the consumer (the client).
There are two parts : The councils which are to spread the information about the
rights of the patients and the grievance redressal forums. The latter has been
active.
c^L .
There is need for certain assendments to the Consumer Protection Act to make it
more effective and at the same time reduce the possibilities of harassment.
^^-s2'
<dL O-JgpjiJUj
rxic/fe
^stT"
7. Use of Technology
)
-<Sgr~>
^-PA —
gx>
<5^
“————-
Advances are taking place at a fast pace in the Medical Science and Technology,
Not all advances in technology are assessed adequately. Many are used
\ ^y r^e V^<s^o2_
prematurely.
Some technologLigs are misused. One example is the prenatal sex determination \ >e^ve^x?c/
and female<^rticid^)foHowing it. More common examples are the unethical
xv-lz?
promotion of drugs and their unwanted use. Tkp
^cx
/Ze
}(S2
K crvy-» /o ~yS>>O~Xyi
~ <g
fy
vX.C^
8. DrUgS^ind MddernMedidrfe vis-a-vis Traditional Medicine
<^dL
ecs<
Fast developments are taking place in the field of medicines. They are protected LZ7
dudj^^Q^-t
by patents for a period of time. The firms want to make quick profits and promote
them without adequate evidence of their utility.
There are many traditional medicines : Systematic as in Ayurveda, Unani,
on
Siddha and Homeopathy and folk medicine, often disseminated in the oral
S^cx^ldL
tradition. These traditional medicines have withstood the test of time. They may
not have been submitted to double-blind studies or the conventional tests, these
mc^/^ ^Concrmb'
■ may not even be appropriate. But there is need to determine the efficiency of the
c^> <^el)
drugs and ensure that they do not harm beneficence and non-male ficence.
/L
q
_
"XTzJmJP'
Once that is determined, the choice has to be with the patients autonomy.
Idc^lfk
x^bc^lcfLfa
y^L^dld^-c- f
c?/c^y
£:l>.
Vo
ZY1
,,
Y (Z^n
Icspy^CL-^l^
o.
CeJL.
<^p <S^
L.
a
c>
YE>
Llch.l^,
eM cs>^>
PC?
-
/ 9. Manpower Planning----------------------------------j Our Manpower planning leaves a lot to be desired. There is need to determine
j the n^eds and resources Health human resources development needs strategic
\ planning which must be appropriate to the needs of the people and relevant to
\ the feign.
\ Manpower planning must include all integories of health professionals and health
\ workers ( paramedical).
k,
<<—^IS. Resources and FundingThe resources, whether human, material or financial, are inadequate. The
resources are also unevenly distributed differences region wise, rural Vs urban,
affluent Vs poor. There is need to increase the resources and allocations and
while doing so, to pay special attention to the backward regions and to the
undeserved people.
The budget allocations are totally inadequate, both with respect ot the needs and
what is being made available in other countries. There is need to ensure 5%
allocation for health servicess at the centre and 15% at the state. This must be
achieved progressively. There is under-utilization of the alloted resources, large
chunks of the finances are surrendered at the end of the year. Poor financial
achievement is paralleled by poor physical adhievements. There is no proper
management of the resources.
fP^^XC'-j
^ll c^Z^o^c^
;J^ 6^ /Tc-z-tKoo
t>7 //^ (Sc^n^xP <5f ^^LcLC
f]i/Z^g-erz-^^Ae/gCe^
o^-xA
/V^ ?2c2^>eA,l a~< ^)C^-)CX^\
d
h-^
/•
’^Ooovas'i g^z)
IlcycL^K^i
<^dA ^e^LC^cf
/9<TYl ^teo
/t>
11 07 ^*n C2 pe^x4
^/>24X*
Ccr->r7keX^C
^L^/l ^y
all
xX^'vxc^ y^yA. x>vvu^v^o4aJ^
.
6^jA.rnA>v^l^
I •»' Z)-t£^j*vZvnA
jsmaX-
-AP
r
x^uWsj(!jfc7^/Q^u^ZibriA. K
'vOkXVv
CK^ (^d^vfct Zr
Aa^L a^X_
--<Xw /^e/fe^Uv (Z(Avia
aaJ
^L >/fe
^5-
^>A^'Cckx\
=~^<i-----------
-^^L^^.tJd.^
/Aj^
2rZJy.pkc^v^ ^vvi
U ./fccvwo^
za_ <
_____________
SjaxJv y^x- Ao;^ cXv^^ .Ct^W’YVL^ .
!
y
Avd\2c
—t~/tijJ.9, P>2_Qa_Ca>ma^
/Cwll\j
VHvv—
HXCudu.
fc-fa-^A^tc-incjeAXty Av
A^
_ Gty^aaj^
IL'tL —
/r
tXA^fL/vV^A/Vfi-^ ./s? a/j ^yv>A |
*nrAA> /^Aaa> y^VzCrC-Oxio
^CcLcv^t
yA/tfbb^AM/O^ zl/^^^ViA^^^/Vx/b" y^_x>w^L<<4-b^vy,
[^v^A/y^^t^Zc^ } ^vUvL^/^vvn^
V^Ajk^tu^*
'v<',?p£^?'jo^j3T^ ij
/
tj^-i^-iy' ~^7
M’1'6z^!^}1??a^' yM-V7
< st^-cp^
^vi-va -Vu-vx
1 Q-^aa^vuj
^~^VV/Vv/y^)
c?v^'
^°l y^'^AAyTV^AAyvwxx^AzQp
t
'Sw>yo^'^,7j7&/ * t>J3VWj^Vv^7^>
/ f~^> ^AYTr''X£|'y.
ZC^'V\»rtn<3^->)^
-^,^w vmy^-^^v-j^yA/y ^X/^f v2^?y^'v>^^—T'^’^r>'
~T'v/vriwy~>g>
MAop^-A^r^y 'rv'V^TX' cyrjr^ Ayp2rT>' jy^KAyV/ ^t£,
yy Y/y>Aryay
£>
t^-t^
y^jv.
f ^■yA-T^yw^'^f" ■^•^A_yv.
■»xas>-’ o'JD^T’Vy*/' ^'vvvxf? -y^v
o^- -r^ay -g^g-^
-y^gry' 'Hw^yvy^ "sywy/-
rm
.y^yryywjgy
-^. ( vy>tJi2f yp'V’iy-p-i] A4.^ , p^yy^!n^‘_2yaAy |/.^y
■yyp, ^y^yV^y
f v'XWy ^^’^^'I'tC. i^yy^T^ '
v^T^y.y'j^^T^y^jaAyy Y^Ty^y^- -^rr^y '’^)rfVv^ ’ ^^Vc>/
■■ v'yYv^'^vw^
tyvYiy/ z v^yy>
K^227 ^xv^/
yy
* //
— A''^-
33^%UOi^Xi?
^-XvTXAJ^
jlC) -t
WTvU^
"
^>27'^23] 7^ ^7
"'fyA
ryup
vvx>
^a'v^aax^^zI A*"*-<>£^ -^y^C (
'J
f sXVTVvW*
/ cAA^^-A^HTyKjyyU.
^yjj
Mprs^
v'y^w^' ''pTWVtx p^/^o?y ^3y>zJ'-pzy' ^Z' *^'
'v^> '
T'T^f^
jyy^yy ^'^-'
Vt' K>x Cx
V
-zet^t’O- A-^, />v A/^^^VjyLPtvv^
3^- Aaxlaaj'v cjl^
bXjx<Xx3 6VX C^LuZ
caA5L
h-A/vA^a. vt # x. v\Xx-v v
^W\JL U? H^cct
z^~~ ^Vv^GaJuVLC, ^xJZ
<>e^x VJr VA >
r
A-<<QXAa>X<Co CAAaX.
y Xq
& ^x<- A,v^^»\jbVk.^^X^
^
k
__________
, kr$v
f»J£<r<A^l<ivk3 <^v<
K^~
'<-iXA.\\i>Jj^ j
<Z/X—.^o XOi-a
njX X ^/w<UxA^ S^/P c^LtK^J^.
Xzv>Ax
/sLI^^/a^AwtJto 4vWX
/b/^ c^\rl^:
“S^^- X Zt k, vXi V--1-X L'^r,
za^wUzvJ^X
\
4^^. Xa^MAXXO / A^jyL-<XvvX
-^itv . PwZyXvu>k(
* x^-vrv>p*
"’Vf^
•yv ^
js L ^y^rvAAiTv/*^ '^ryy
^7^ yr>^) vt^'YV
■X?T<y'
-p^
Yp^:
' prfvi^^
yy rV TjA^vwm
f4pvvp(rMT^ y-lrrYYV ■X'zvXv^~e^A|
>
‘ rv'''>- O^'Wbt'VyTi? ^p^ypj ‘
iowy>^7 tsv\?
y^t/ '^a^ ^7^°|
'^X^.ru-y^rz/L,
p'^2>>
-^Myrt^
^'YYtO^^r^vyy^
-wv-
7nxv^/^<7~v\X 'vyf' ^wt?
22^
'/p^_^ p^'h^
™Ppyy)
-
y^'y^.r^V '^\r\y^
-ywv
L^pr^/^o c^
-yvv^^^y
aAy,jy?^^ ^TipAj^yv^Yj
^prrpyM^ yrp'ixxv -^npV^
'
r ^'>'^»')y)
Y'y ^HA-^ (2p vy ~w
pvv> oy
2'VK_'p<lA/
------------
^ryWk^X^VTMyv
^zuyVv^
7)yvx^_-^a^
o.
^^Za^uL- VL&rrQ,rikXX-
/-r~i. F—l I>Aj\
L
X £C yxCvO^l
- I
^?<
7. ^ /— ^^T^Z^vx/t;
6jv/^<?vvt'«Ll^^A£\/e..
yAiwur/e_
/£Xv\)
Xa^ ^gUakA-X,
{
TuXbc^CCA^K^f 1
CKj\^L.
A^^v^<xtc>^
T
S'ljtdLx*^
Gy-LZVv^
(4aaA2J>Vs3^^
x'A/vka
z
J
ZkSvML
' ^JL 2^'Vux^
^<7VvV/t'"
v^L /Zcwul c-j^^ (^tv^4
/Vg^Z Zv^U^
't^vv
-wx
^^^iCTOvUi
WlA^ y2A^{r>^A/vL
d|
C\^ilkkdjyrd^
^Vo Wv
>y^iaLC(
^XL-
V>O</Vx/^yu\/Cjj Z/\X4JL H<X>v^TLArf?t^ECX
-A^ >Wu4. Zr* cZ^^T^hJ^- Jte
» O^a^^AA^Ua^U-
zZ^_mr
Z444^^ZXe^
x<XKXJLr^vo i^~l^
— >vLz?^^t^OL , (9>v<^y^3^jt7'-AD
lUVu-
7
5 CZ^^fevU'YWH -
l*J\sltZ /{1\SLj
A^ZgWv/pFV^v z^vZ^WX^^
‘^urvvx-/srrx/^cv <j XwvytM^|_ /ovv</j
/^47^7“
X$ tXxUA^vv^kiL JkS2 ^ICqJL^ 6<aaxL /^ZUAajXCXz) /
>VxJx)
ft\SL 'Vlfi.exzto
^3?
-^//r\/vv>wu^i
^v^L /tL^x/^A/t?
^/cXv^yoz v vV< yX^>WxMn^ ywL\jaZ^ XlA/X<<c/kAJsts- A-W ^^AZ^^Axta
CA.vajA. .^CjxZA?
v-cz^ VS ^^<^^xJ^\A^LCo^Q '
( ^UU\J2. to XLaj?^
^A^ryyj^v^ hJC^\\_\JLJL^
p
f j v/g'* ^tgu'/^TS-J^^uxfej
3
(“^Q
X
1 <
L-xAAev-
oJ)
C0-4
D*SCQA S
f^jL^f PeJJx eg
C
cS-J~ C M H •
3.
tk RS
3.
Z-Cf
Q-C r
S.S.)
/ ScC‘ )
r( u
d)
—6^-^
£
rf s P A^—
h
Q
Csi^sjl (r^
7-
y
—-s. ? J
a.
3 .L^-J J
1 MH
/X' dX
/s', i
__ t L Suh.- P'
cf If , f~^t_c^
t?
c Lx.—^Xo. ■
TrJ
\'c> Qe
I
S7rt
/2 Gr o » f
i s' £ o
—n /is
«-ir .GrrA^
/
<rY^-'
$
0 ^J,.
—Vk
Qy^ / /^>H
p
V-cAsa^
^AV
■j^C S r>-^)
■’ 15
l>iQ
' k-
JoV)
I
fT^’l o
t
3a<Jre9 V^t^
■
\
^xr^nJV^c)
/
5-
^x5‘(’l
^-rv<o ^w<"
1^-7! A^j-r ^<r>^^QgJ ^^<*<8qc .(
5-vf-n7^'
V<b~Tt 7
P^qfSr-'^^ XSy^
' 7'5 t9^ 4<5 Og
___ _
Z’
I)
^sk'
>v5
3'
■rj
'Sat’ c?1-^
c
OHb
eiLbl
c
&
Ley
c 3 I r- pi^Qou:
■J
IXV^A-K-AjO--<>j£C>J^A
I'f-A i^jaX> (L>—A-O-
G
1
t
I )v~>
->^1^.
" ^4vC C-a-o-VCsJ
j>A^(r4lL
Il
.•7-<£i—5
r
So^
f£>-Xo^ ' S=!c- ^Cv>' ^Fsb-Ccbc
.JXH’-r H ->—cK^5 J
. c ’fvA zt-e 'usj'i/
r>»I| a<JIccCa C?
^-Vc
— a-
_ &
‘T
‘l?-
d^r z
L& l^’
UcU> p K
1^'
J^r - 1
/^O ^-'Cj
t^THe
F F
i
'
w
9^ vX-Aj I
c
•4
’A.
^~k_o—e?
l/^-4-
A\)r AJ?
r
1
Tp;
/yj
-
l|r»-~aL.e. e^
i c
to
^s^L.
u
. L^p-^ e. —
2£1
- F ScF
'
1
iXbt
r a
e^<J) v Pj2.cJ rtc
e^frioQ
UbJ
H
f
t^4>
I
"H’l
■t> <?LfKv 'LFj
A_ SbJ-4 -sbiu
f
..^'(Vb
J
oi
' 4^,ji
•' .V
—
2xH1
<a
V)-d?
—
g>
/
n. I
0
C 7
l<7< /2ei
] y^2 '2ms
la 6 M
caJa
U' /^Lc q
JL^V Ly
^Q/tf 0%
Os
(7 *• rlK^
|CT) <"' V L>l\~.
-
Q ! ^-
y y iv •■ p
V
ptv$M<
r
JUU^ . pUf
VbyS
c V.a .^AT^V^J
kxA-J^lmL.C|
2
—
P
'« lb
v.
HO^ra oA^a----- -
XAfe
/p-<52C-X e>
7
^L\
<£tL-\? o
^2jaJT^
,eXf Xr o^v
c
------- ^A> S
T
a.
^v
.Uik £
irv
7 uk
>yp^ ^- C- t>^
'
■•M-5rL-^
j^f
C Kok
7,1 Uf <| 77
7
C-^Vr^ /v-v^—
I" -t c^^X.Cj
- • r
p ’-<?> -
VM
o<3y^
aP
(I
Z
g>>(
^-^OQTVzy
113^^ h
rn /
T^-S
wm
) cr-^po
{v'TTJTM 2TH _ X
JVx
id
s^^CjpCX
I 'Hpy V'J
3
0^1
'^3
\ Y a’
Jrp
^oYp^nr
■S’
n
l ^fe 41
i
(/■—<7 71
—0
1x
G°
C^s 302W'
■ '-i^pT
~-| X^h
\U^-
G^y^ —raSjjQ
^yx-pxgji
s^w^o
'
A
'iprtVvTS A-W
,y%
/~
■ a c
*yj —'
n ^n 21 - ft 12
np 'p 7
X'
c
FC >p
-1--
'4
i^zzkc. i
r —vg "
- ----- Y—o
S)
-—
3 .
■X
A^v^o
mm*5 ^cCL?
Imm t Jd'—-
4
XI
’V^i xs
xn.SK
I
!-s Q jBi I \
Q,
<2- .
LU-^1
3.
J
u
-T
. V jX-XX
<
C' \
I
SC-^
k
J
- su
Cs>-
^cy>R
SsJ
cj}
p
t
I
j2_qx2^2_ —
IM
x c
e-'xkJL y
^□C-Pac^
{|. •'
8r
5^ l2
1^.
c
jS
rc
OX—G? C’- -£
r~ f
1
CJL^
V£
■
cxq.L^
S
«=•
c
’-•^
t^L^ptr' s^
\§)jl> Ml
/
<h
' 7U
r
aW
J - Bu
L
- p A . L [K
Kkc^^
tA(c
e
plLc-~f
P^_Q_§Q
'-j-x>^\ - 6^
7 & J Up^V-j
45^0’
i
-. ixr^-^ry /V
—'"" i
f"^
.'•A\i~rv
(r
NF? —
t\
F
<n
T
7^
°S^Z7)
t^^0
(j3"^'*---- ° 7-^ 5<
Q 7 C7
<-fS^
&
’
T'
r
‘t1
.-^
5Q Tyf
N5r frf
1 I ■ j ■./-
^i) 'y
- JL^ 5
j- pin
I. —
r
n -
—0
*
V
J
O’
4
^ycrsnr-TP ^30^
°s [5 V^1
L
"
9
Ip
I )
-y|y TH J
' ^1
■Z^
- NN
> 'jT
13
o ' -- J..k
7
z- (JL^TC P (3~3R>v--l
.
. ZZ
CM-Xt
-
C
l^r
.Q. ^A-O l
<7>t7
Jle ^2q9
. /7rVr[c
/I^Lu
---------- -
T- L< J
jC3-
JU
f)
dA^Q.1
pA^ot^Uj £.-<>
lb ....
&a<? ?
1
£LQ C U -
i-■■ c V
)
t !
>rt kp
n
/
h> t
■77
7z.
x .UJ .;
^-^CuQ.
/ MK
c
<
—fieX-——Q *~^Qit_.Cj^
<7
i'-VU
--- L Z *-- ^1
<2.-4 /-
2^
Q,
If
7
-G
7
/-HP
^P<r^-A_u2_ trv<g> ?>-iL J(
^?'\S
— £5,CJ J
-5
<
t^CLC-’l
I
j
4
r
3J
'A
^j.v 7-^ r fUd
CL
"G Xe_
ZL T
-^2. ^c?rO
L\n f
L Js W ^5: —G-L^)
t^£
LJ <5>
/)
^0^-67
) t—
7
A 4— ,/VO bC^M. ov^-Q t
o
1J
4'^ “
?
j -
" ^4>pj
5?J
^F<!
J;? -T
J^-^5 -TT.^CJ^
;
^,-jr^-o
FXF^T
.
ZK I AH
T
^FT^T
J
.
J
j
^-iZP's^-g ' -n^£
,
(f£?
i.
np°
5-
- ^J4 •<
srxO |
c
~6
d
h^l-.
o
<3-X>'
-^j
¥
nU
- Jlw
-?
'n
s>
->6
1
I
’.
r
(JyZ\V>3~v^5T7
X-V
FF^ uCT^
Er i j Efe
<>
-p^=^r
■j
^SZ1 ''»■«=’
*" J~~~~—^~'■—<7
/hc.
^4^-/)
Q
3 r-<-j»-n -v^_^K
• ^>o-^r<5^
j—ayA)
b
„J b
a
J
■ c>!
p?h
-
.,
^2cJ t
Jo
/P.1L
2.,
J \fi \ n Ji <<
L
2 jCP )3 .
f
k-^-
' \
vV
iXX*'1 *-Qg~gS»
z4j^t Q
Lv/J\.
(2'
I/O
i
X'-'^^LA^? --(
C
6^0
K_X
-v.
&
pAl
a--hX-
Jx
e $
rX^txJ
(5 ■
0
"■j 3^ Md3Xvs>
CL .Q » -
-JL-piXf
aJJJ'-Jx - h<—m
z:.. a4>4>'<x? ;*; k - C
k-
r
5l^
5
0 £>e
C^'xKQ.^-P
L—
s>
Ll ’S.c
e: S
,L tK vlcCf
y to'
kO .
/oj'
1*—'
Ytol U{cx S>—
<J4-J—(Q C, <-5A~- /pk^’-5©'’-
<2 u- / ^4pX
^2^'. ^exAhn_Vfc>
>?v X d
pVl
— ^ V_,
l^ —
£3^^
V>_rvC’ Aa C_L?^
O-^- s>
--------- £?
t; ((FT'f
t o
s>
|
I
'X ■ 'xr^-'j
—t“5x
Yr—
W7
1
~Y; 3 ......^
Y-Y?
-^crn H
r^'Y
^rY?/
j.
0
|
~~
o 0^rx
-
^=^V33 - W
I ^UW^
^1
oP3^ ^JYSK^I 'y^
AJ
Kr^-s
^1 3 oo
"
u- (iT^VY 1
.silF-^ xrvv37
XIIe - o93 /
—rx.— z^Jr
> ^<3 Z)1
-4C55
3
4
l~yrrYcL ^-
r
I
1 8
71
's7J'vcf~' $lk,Y
~ • '5 <?
"cr^-‘* <Mo-< at-
C AX ■ A>^);) J-MV-H;
Y—ox^o-n
) a v^ct-^^oY
rs _
6;J^
>nr"Z>
(Y
5 ^'-z?; ' «
■—
-------
r
■
^V1ZV
pr’^FF
Vi
j^i. ^rr'"
Oc^l
— f-rW
Cl
Ys4^xY
L
GHOc
k
1 i^n>^XvMiP7
C.~%J2cJ
xAr r»t
teJk
c
C
c
-F-
?•<
t
■/^
^f52
U^scxfits.
pc
£JL_ /5V\\
'
7 F^.
) <2js^-c> v-£’" ' ‘' ■'‘■"
-p
. Ti-s.^
, S
PW. £U/Gok
‘ '
<5* -^V",
. , ^-e^p. ^1
cW
cc
p
—
l
i
2^1
t ,s h---2?
S.^C'C'
V.
IP
£ £)p
,-
,p
<-
p^c^.8 - Jj-J5 .
<
e- rpl-h. ' rL C-.-fe JC <•>.
r-
-
^j\
<r
_22^_
ci CU-XT
v
‘
—O-S^ L.2^
I ‘-St-x
s
<n^ ~‘
'X
>n^
i^q
“ "I
-c
-rN
/"^Q.
2r^?xk'r^C
- >V4
eo^
n 4 - —ci’
-J
s
vs
i ' t->j—^<?
qX «>T^
>
■■’
Lx
uxk
C\a_J2.
A(
V'xA
Ax
ju^ov K jit-X
g>x
oj
5-
- xsv.— —
Q £VoKi Csz—X-Q. /L^-®
■*
<<
0|.
4- b'-Aj
•
<*-4
^^2
V-Lj’ C|
<1 - ^eP'zp
Vs^-5^ b-p-^c
•.■ r-^
?hQ
4 dM
—p ' |X
C r -'\-
<_t>
<7-
— M i c\A-XI
r^C <Cpv pf-1
'ua.
. fus
(X3X" 5-a
V
hVrtk^
OJ\ "
?r> 16
lr
L—Jts—S L^)
k)V
V- mA
Ccsi-jL-iu^
.—* (^L—
Cr-O-\S^_|
o^i^cL
< vAVce- *—
KT - Ql-S. 4
T\L -
Ss-
CLj
h-&
cAnx^
cXV-st^>
<? —
'fs^'-^
epo-o'bAp
iW
tt-
( Pr^CiZ v- c
j^x^Qk^
ci
\_A——Q.^*—■
qi<7^ Fo^
- p^XlKJUp^ao
OP<J -
L_=z
A
<■
i—X
<>Pc A ( c^ ?A
-
>rt
'M tiJ ,_
acO
F>1___ G
4*
I
lQ-AS>^
Ni^T
^^AA>2Jk Z^
<?l>(r<o^j_ C
JI, jj .
€ c e>o—Q
o
xJ
»=^£ t
e tnJ
-1 )V —• cS^tt-%-
J PU
------- ------------------ Sc---- ! '^
P~4tc tUlKTA-J
Cn O> <_e----
X
<
C-<Z-
1
nt,
-C
^1
s<-
WjC-A
|K7 rf^p^v.
Q
I^VSc/- Hir,
*~ty
f\^rV
?3®r
^ru
■ W/U'
WJs
Q
Ca__ -^2
\ K?
' p ov - (^L^,.
f"
tS M
b&us
1^ Ap
& C2D
'ScL^
S.-
tLl^ ^.oj.
3d-.
ns
J.
kPilb/^, Cu-P (PP§
■
Lj
^A_e
k3i
3^
\c-
P 17
t" -
ap
_fczA(
t
pit? k
p>. p -
C
— 3f
^." p^Co„^>
cv
', Sr«-eO
-
P^Q
I c
kv
Ufe—
--- < J /^MC ' ligfc
L-J5. C.c. f:i'l t'l’-pj'' yl^^P''
Q_^^—Q
pL^v—yxaxi.ptx_,
j^” >.
29
c
r
___i l" Pto— -p-i-i’t
_jfc> /Ze^!
'.^o per - ~c
4-
VA
/■
g.
p
P
( kVPjL<
- S^
p
Jk S'p (SS2>
ly
e 0^g_ . '
.
I
’Y)^
0-
s
J
r ^5^,. 57 S’
L
y—
r^r-)
- >w^-<3 -<■
5'^r
ww
k
:
%j.)
'
^V5:?
■T^"-
°L 1
_>
(L'c^
^hJ t
- x-e^^-n -j
r?' xx
^)
h
-5-
-
ssiL^
> Vl-> ^(bJX C^eJS^j
Rr<<—)
Nic
KRx
P
the Dirsift NstrnsiB
Pohey fmm <s
ComisBjjmeir
The quality of the food grains and other commodities supplied through the PuiM©
Distribution System {PDSJ needs to be improved, if nutrition is a key issue for
health.
»
The health policy should include provision relating to safety of patients
(consumers) - safe equipment's, safe blood and drugs and safe environment in
hospitals and nursing homes.
RecycSmg of used syringes, needles etc, has become a racket. The health policy
should provide effective control measures and severe punishments for violations.
The health policy has a provision on drag mfoirmafttooi) including warnings and the
role of pharmacists in providing information to consumers. Independent drug
information centres are to be set up where consumers would be able to get full,
accurate and unbiased information about drugs.
Though the Government drug controllers issue notice of drags banned,
consumers have no access to these documents. Besides, the list of banned drugs
are in generic names which is of no use to consumers. The health policy should
make efforts to give the brand names of drugs banned.
Prev®f?t8©oi! ©ff food aduSteratoom.
It is essential that this Act be amended to make it more consumer friendly. If the
National Food Council is established, as given in the health policy, it should involve
voluntary consumer organisations.
Other issues to be included in the policy
A chairteir ©f paffiieinte rights amid iresp^osiiMiffigs
A ©ottesms ehariteo" foir h©spoteis and nunrsing homtss
Roght to Unfoirmatfon to (patients
' AL
a4<:-
D:\Pradeep\Balaji Faxdoc
26-04-00
BALAJI FAX
2 080 3303973
17:09
0 001
- T ■ VtfAc*x(ovw
I I' I's Po i > c. y
bu g g e b t. i. o /s t o r t bi 0 r • ft f A b I ft t ion a 1
---------------------^e^rv"»
£j *v cup
pr vsnicte
& a v1 G1 ij r\ t a r y c o n i .i m r? r c:< r g ft i\ A vs t i c< n i.‘2or >• jth:j to
to bf-*
.m ft >;■ c t h e f c> J. 1 o w ,:i n g s i •; g q e t .i f;■ n &
c on.Burner {Au? 1 f ar ®
wf
A nr;! i.4ded
A n t hi e D r a f t N *< t i o n ?. 1 )• 4 <? a 11 )’ < F <,-< 1 A c. y .
Thfc>
q u a ,1.i t y o I'
t fr e
f »oad
n >■ • a A n b ft r/ d a t h f v
co/run od.it. i.F'V
p? J. i <? <A t hi r ou g h t. fr t? P u h? ‘I, A c D i s t r A b u t A a n L> y c:> t f in ( F 3 > n f e d b
the I. /■•* y .i b -aU <-? f' o r bi /? a ] t bi l:?e i»'*'iproved i f » i u t. r A t A o n A
S-ui p •-■
tQ
to
p r c.: v i. h A c» ii
r 1 a t i r. g
K3.fr ou 1 d i i/c 1 lkIgv
The
Hc'alth
Po 1 .i. c y
S-hilH
I
1d
He?a .1 th po I. ic y
i «? con^iim^r •“ w
p j is t ,i tv n h &
Ba fety
ot
a n d «■• ft v r?
onv ion ssft'fe bl cod j, d r u g
tT/BlTTf K cS f E- equipment s.
rt m’ ni. j ? i hi c:- &p ;i. t ft 1 & ft n d n l i r i n g h o.«ft e £■
r ,i\ i: !<..
s y r i n g c- .*?• < r. e d 1 e tr ♦? t c . h/a ?;■ hoco/r?^ a
f
-f
fi?
/
y
j
,
Z(
e
centred
p.io J. i. y if- hou 1 u
p r cvm- :i de
pun.i^h./fjfcnt.'j for v-iolators.
F: fjf c y c 1 i r> q c? f ti *& & d
et .
Thh£? a 11 bi
njOcV'-ure?.; and
h (?:• a 11 h pci 1 i r: y la ft
a pr rr/.i b A on or* d y ug
Ai n •format
f or ma t i1 on
j. n •
Tbf?
c. ]. i ,i d A (i g
kJ ft r n -A n g b a n d t fr r? r o 1 e
i: p bi« a r m a c A B t. s
Ai n
p r c< v ?. d a n g
A n f d r ma t A c* n
tw
c c*n tamer s. I n d <f?pend i?n t
d r- ti g
i r. f ar m a t A a ti
CCTtreo
are tc be Bet up hd-iere consumers won .1 cl he
able
to
g e t f u 11 , a c c iJ r a t £• a n d u n to .1. a y> e d A n f c<; • fi: a t i >. :< n a !?■ ou t d r u g b
d r- ug s
not .iceat
t hi e
13 v t d r 14 g
c. c« r » >: r q J 11? r & i •■» u e
Th <k i g i i
Be-dacumv-’nt
GTTi F,:LUr»fcTr £;•
HftVf-? nC< ft C C <--: f~» «• ta
h nvi /wd
Uih i c h
Hit? lixit. erf banned drug's are in genre Ac name*®*
’rsA di-."-:;,
rr- r» /•■ e
#ho{ i ’’ d
no UTt? to consuffiGrjs► The* heal th pr.l.icy
i£
r-.»'
e 1 for LJr; I i j ;j j. v e t h e to r a n d n a in e f- g ' r d r u y b a n < i e d Fv #?v€?nt ion cu;
Food
adu 1 t.f?r irct. ic.r:
it <nc?re
pstab ■•
i. rr/ol ve
'I h a t t h i «•■ Ak: t to g a me n d t” d t. o ma i ■ «•
•f r A fnd 1 y - I f the Nat .1 ona I F&O't> <:c>ur>c j. 1
i
Cpnc3LK-2{J»T
ft
gAven
the
Bliou .1 ci
11 &-h c-? d ,
ri s?
b
g A v v? n iin
n t
hi c- heal
h t? 1 th
i. h pohey,
pj o 3 i c y « It
vcr. 1 ci n t: a r y c. e n t-A.i nse r ar q a n i s t .i o n £■ -
1 sr-
11.
nt.lier
i
g? «. if.e n I: A a 1
’•+ u t: si t o b t* 111 c. 1 u d ed
i r, t h t* p a I .i. c y
A c h a r t («• r a f p a t A en t. “ r A g»i t b a n c I r e i-'.p ri v\ fc-1 b i J A t ;i f b
A cit ArenB ’ aharter for hospital-B and nursing frames
R i cj h t t a 1 n f o r m a 11 a n t c • p IA e n b b
FTWi:, ’/ , G. Mu r a 1.1 dhi a r a n
Fftx; 3303973
Ttf l : 3ACF170.
Fn»a A I ;• /y nic r o a t ■i?h ot; /na A i
c: o/n
orr'd’c// >/
I
S'] 4^ Ter.
HAC/X’i___ >
e»u.nd'4
^“^7
A-e cl
/^v
>/A^jeoo
ca>t
Re:Draft NHP-Yr email dt 3 April
Soubject? ResDjraiTtt TWUP-Yir ®mmanD dtt 3 ApriB
Date Tue, 02 May 2000 14:27:17 +0530
Fromms Community Health Cell <sochara@vsnl.com>
Tos pruthvish <prutvish@actionaidindia.org >
29.4.2000
Dear Pruthvish
Thanks for your email message of 3rd April. You will receive by
separate post or email the Proceedings of our meeting on the draft NHP
99 with all your suggestions included. Thanks for making it to the
meeting. We need to discuss many things
a) The points about the meeting to explore the evolution of CH resource
centres in BIMAROU
b) Your suggestions about CBR and HCWM in RGUHS syllabus etc.
We return from a short vacation with the boys mid May. Do get in touch
so that we can meet after that and discuss this personally - not over
ema i1.
All the best
Your sincerely.
Ravi .
Encl: One attachment.
Nam®? Review of Draft NHP-99.doc
| [jR^i^.ofPr^NHP-99;docJ
Type: Winword File (application/msword)
iiErocodnimgs base64
9 0'
1 of 1
5/2/OQ 5:09 PM
Draft National Health Policy - discssions held recently
SMbjecl: Draft NatiomS Health Policy - dnscssionus held recently
Date: Mon, 03 Apr 2000 14:32:41 +0530
From: pruthvish <prutvish@actionaidindia.org>
To: sochara@vsnl.com
CC: Dharmaraj Daniel <danielt@actionaidindia.org>, tripathy@actionaidindia.org,
harshm@actionaidindia. org
27.03.2000
Kind Attention ° DR. Ravi Narayan, CHC, Bangalore
Dear Ravi,
At the outset, many thanks for involving us in the discussions on the
draft document on revised National Health Policy.
Apart from the valuable comments which came in I suggest that this
opportunity is made use of to take forward the agenda we have been
having over the years to revise the curriculum and approach of health
manpower development specially with respect to Doctors.
Kindly let us know in what way we can join hands with you . Also, we are
keen on working towards incorporating Community based rehabilitation and
Health care waste management aspects as part of curricullum of Health
care personnel. At the outset should we think of a meeting with Rajiv
Gandhi University ? I am sure MSRMC will be interested too in this
especially, the second aspect ; and SJMC with respect to first aspect.
Thanking you once again and with regards.
Yours sincerely,
Pruthvish
lo
pll
- c
/A ho
TA e
£ CuA. C Ce
-c
•
/<7/^
Is
Cr5fZ
L^>
c-f
'i cY—'-
a
/
A e?-rn
/k^
/- c
J
/
/Le^ h<=z^
1 of 1
ii’’
4/3/00 4:23 PM
■"lAb
Re:Draft NHP-Yr email dt 3 April
Sunfejjecte ResDnrftf NHP-Yir enmaiD dill 3 April
Date: Tue, 02 May 2000 14:27:17 +0530
From: Community Health Cell <sochara@vsnl.com>
To: pruthvish <prutvish@actionaidindia.org >
29.4.2000
Dear Pruthvish,
Thanks for your email message of 3rd April. You will receive by
separate post or email the Proceedings of our meeting on the draft NHP
99 with all your suggestions included. Thanks for making it to the
meeting. We need to discuss many things
a) The points about the meeting to explore the evolution of CH resource
centres in BIMAROU
b) Your suggestions about CBR and HCWM in RGUHS syllabus etc.
We return from a short vacation with the boys mid May. Do get in touch
so that we can meet after that and discuss this personally - not over
email.
All the best
Your sincerely.
Ravi .
Encl: One attachment.
{[jReview of Draft NHP-ggJocJ
1 of 1
Name: Review of Draft NHP-99.doc
Type: Winword File (application/msword);
Eiacoding: base64
5/2/00 5:09 PM
A Review Meeting on the Draft NHP-99 Document
An interactive participatory dialogue was held at KHSDP Office (Public Health Institute)
on the draft National Health Policy-1999 (Government of India—Ministry of Health and
Family Welfare). The meeting was facilitated by Community Health Cell (CHC)
Bangalore at the initiative of Dr H. Sudarshan, Chairperson of the Karnataka Task Force
in Health. The meeting brought together about 20 resource persons representing different
disciplines and sectors so that the policy document could be reviewed from various
angles. These disciplines included Public Health, Community Medicine, Clinical
Medicine, Demography and Statistics, Management, Nutrition, Social Sciences, Mental
Health, Research, Health Humanpower Development and so on (see list in Appendix I for
further details).
All the participants had received a copy of the draft policy document and had come very
well prepared so the meeting brought together a wealth of ideas, perspectives and
suggestions. We hope the policy formulators will take these suggestions in the spirit of
solidarity in which they are shared.
The minutes are compiled into the following sections:
A)
B)
C)
The comments on the overall framework of the document.
Additions, lacunae or omissions in the document including suggestions for re
wording, re-orienting or re-integrating parts of the document. This is presented in
the chronology of sub-headings in the draft document and the relevant paragraph
number pertaining to draft policy document.
Comparison was also attempted between NHP-83 and draft NHP-99 and this is
enclosed as an appendix.
A)
General comments:
i)
The document is not well integrated. It is not clear whether it is a policy
document, a programme document, a plan of action or all put together.
The language is very variable, quite uninspiring and varying in quality. It seems
to be many different contributions put together, unedited.
Editing needs to be done, effectively keeping the language crisp, brief, readable
and formatted in an attractive way, with headings and sub-headings that make
perusal interesting.
Some places the wording is apologetic and in some places there is far too much
detail for a policy document.
There is no sense of priority and all issues seem to be given same importance
even though magnitude, relevance, impact or need may be very different.
In many places the statements are ambiguous, not specific. There is need for
clarity and specifics.
ii)
iii)
iv)
v)
vi)
D:\National Health PolicyXReview of Draft NHP-99.doc
Page 1 of 14
vii)
Considering this is only a draft document some of the above may be accepted as
part of an evolutionary process but a logical framework and professional
presentation is definitely required.
The document should have:
(a)
A Preamble—
A situation analysis —
(b)
(c)
(d)
(e)
(f)
B)
1.10
why NHP-2000.
The health situation.
The successes or failures of NHP-83 (including
where we are in the goals indicated at the end of
NHP-83 document) and why this is so.
The Vision/ Mission — Policy of Government in 1999-2000.
Then all the sub-sections in the present document — slightly integrated or
re-arranged.
The goals of the policy, the monitoring-evaluation policy and mechanism
by which the policy is renewed/reviewed through action and evidence.
The Health Policy document should be a comprehensive one, so that the
other policies related to health — be in population; drug; blood bank;
nutrition policy; health human power development; AIDS control; should
be integrated into it.
Some Concerns: (only key concerns shared in the meeting are included)
Decentralization:
In spite of increasing overall commitment (Item 1.10 of draft NHP-99) to
0
develop models to show how Panchayati Raj institutions (PRI) can be
made responsible for rural health care institutions, there is a tendency to
promote District level single health problem focussed societies for TB,
AIDS etc. which contradicts this commitment . This distortion must be
reviewed urgently.
As a preparation for transfer of decentralized responsibilities to PRIs,
ii)
training of PRI members and leadership in assessing community health
needs and priorities must be done on a high priority basis.
2.1
Epidemiological Transition:
While epidemiological transition is taking place, it is taking place at different
levels in different classes and there is need to ensure that what affects the 10%
upper class of the population does not overshadow all the priority problems of the
remaining 90% of the population.
2.3
The proposed policy for local practitioners to be permitted to pay rent and
practice in PHCs, after OPD hours, is not a very sensible policy since it could lead
to all sorts of distortions and unethical practices. In areas where there is great
need, and the absence of government personnel, this could be experimented with
in the interim/ short term very cautiously.
D:\National Health Policy\Review of Draft NHP-99.doc
Page 2 of 14
2.4
The need for establishing a senior focal point at the district level for health, family
welfare and women and child development schemes have been recognized. The
States would be encouraged to set up a district-based hierarchy for overseeing the
implementation of national programmes and public health functions. Persons
with postgraduate qualifications and or training shall be posted for
administrative posts from district level and above.
2.5.1
The State Institute for Health and Family Welfare will be established and
developed as an apex training centre to promote public health, epidemiology and
health management skills at all levels.
3.
Environmental Health: is a very important issue and with increasing pollution
of air, water and soil,, due to indiscriminate and unplanned industrialization;
inadequate waste disposal and pollution control; inadequate monitoring and
control. The health hazards for urban population more specifically and the rural
population more generally, is increasing and needs to be tackled on a priority
basis.
3.4
Add local health traditions to list of traditional pillars.
3.6
Public Health:
Needs to be strongly re-emphasised and also accepted as the primary
responsibility of the government guaranteed constitutionally. Even if partnerships
are evolved with other sectors, the primary responsibility should be with the
government.
Also within public health policy, intersectoral approaches to tackle all the
determinants of health should be included and focus on just a few preventable
diseases with top down vertical programmes should be avoided. Horizontal
integration and intersectoral approach should be clearly emphasised.
3.9
Nutrition: should be a separate section and not a sub-section of Environmental
Health and Sanitation.
3.10
Important to ensure that the new focus on micronutrients should not distract or
distort the overall focus on malnutrition. The basic problem is food available in
the diet, not absence of zinc or iodine by themselves. This will ensure focus on
broader issues of Nutrition and food security including:
Public distribution system
a)
Availability of adequate cereals and pulses
b)
Importance of kitchen gardens
c)
3.12
The public distribution system and nutrition of people have a close intersectoral
link and this interphase should be mentioned and the focus not only on increased
D:\National Health PolicyXReview of Draft NHP-99.doc
Page 3 of 14
food security (as agricultural policy) but also access to adequate food — nutrition
security (as Health policy) should be clearly stated.
Role of School Health and Nutrition education programmes must be mentioned
specifically.
Importance of nutrition in health needs greater emphasis in education/training of
all health personnel.
4.2
Tuberculosis: Since RNTCP will take a decade to spread over the whole
country, there is need to mention NTP and its strengthening, not just RNTCP.
4.3
Leprosy: There is need to continue to stress survey education and training (SET)
and to detect and treat effectively without letting the success of MDT overshadow
the reality.
4.4
AIDS Control Policy:
Home based care and strengthening skills of careers at this level must be an
important focus and component.
The exceptions that have been allowed in the Blood Bank policy for the army
medical units may be considered for certified/registered units in rural/tribal and
remote areas ro enhance access and availability of blood for the poor.
Draft National Blood Banking Policy (In Summary)
4.5
The Draft blood banking policy while setting quality standards must reconsider
peripheral health centres and field situations where collection can still be done, to
help access to blood for poorer and more marginalised sections of the community.
4.6
Malaria
4.6
Vector Borne Diseases:
Vector borne diseases like Malaria, Filaria and Dengue are rampant all over the
country. In addition, Japanese Encephalitis, KFD and Kalazar are also prevalent
in specific pockets in the country. These diseases cause high mortality, therefore
all of them should be notifiable and special bye-laws should be made applicable
to all these vector borne diseases.
Selective and location specific vector control is the right approach. Bioenvironmental control which is eco-friendly, sustainable, high cost effective
should be given top priority for long term sustainable control strategies.
The involvement of the community in the prevention and control of vector borne
diseases will be given the strongest emphasis with the aim of eliminating
mosquito breeding through active health education and community participation.
D:\National Health Policy\Review ofDraftNHP-99.doc
Page 4 of 14
4.7.1
Malaria (as in 4.6 in draft document)
4.8.2
Filariasis (as in 4.7 in draft document)
4.9.3
Dengue (as in 4.8 in draft document)
4.10
Kalazar. This is restricted mostly to parts of Bihar. More intensive action
research and efforts to provide curative, preventive and promotive care to the
affected people must be made.
4.11
KFD is only restricted to a small pocket in Karnataka. Proper efforts should be
made to eliminate this disease from this pocket through adequate and relevant
public health measures.
4.12
Japanese encephalitis must be mentioned.
4.13
There is adequate information on the vectors and their biology in the country.
Posts of medical entomologists will be created at district levels. These posts will
be at the senior scientist level. Recruitment of such posts will be made strictly on
merit.
5.4
Backlog of cases with cataract related blindness may still need a camp approach
so setting quality standards for camps may be better than phasing out.
5.7-5 9 Persons with Disabilities:
All aspects of the Disabilities Act need to be highlighted , not only prevention.
National disability rehabilitation plan needs to be mentioned.
School health as a forum to prioritise and address problems of differently abled
children.
CBR should be promoted in the curriculum of all health personnel at all levels.
(When the health policy speaks about involving any other partner from NGO
sector, private sector, corporate sector, GPs, traditional medicine sector, folk
sector etc. the word "used" should be changed to "involved" or "enhance
collaboration with" in the true sense of partnership).
5.8
In disability section -- medical aspects should also be highlighted and the need for
enhancing skills in physiotherapy and occupational therapy in the health team in
general apart from enhancing training for allied health professionals, and
therapists in particular, should be emphasised.
6.
Drug Policy:
D:\National Health PolicyXReview of Draft NHP-99.doc
Page 5 of 14
a)
The goal and emphasis on self reliance in drugs and vaccine production
should be emphasised and drug policy should promote this proactively.
b)
The indigenous production of testing kits for Hepatitis 'C and HIV/AIDS
will be encouraged. There should be increased emphasis on rational
prescription practices, and CME for practitioners on Rational Drug use
should be encouraged in association with professional associations and
medical colleges.
6.9
-------- Likewise enhancing the production of purified rabies immunoglobulin
and their wider use will be permitted.
8.
Trauma and Emergency Services:
While the focus on trauma /accident is an important one — there is need to
include
emergency service focus on two other important and common
emergencies:
Obstetrical emergencies
a)
Snake bites. Steps to increases effective response to these must be taken.
b)
8.3
(reworded)
(i)
Disaster preparedness -- Response and rehabilitation plans should be drawn up at
the National and State levels.
Large government and private hospitals should have contingency plans for
management of mass casualties.
Adequate resources should be made available for, (i) and (ii) including through
involvement of private and NGO hospitals and who volunteers to treat victims of
accidents and disasters.
Training in disaster preparedness for doctors and other health professionals should
be organized regularly.
(ii)
(iii)
(iv)
10.1-10.3
Health of Women and
10.4-10.8
Health of Children
Since IMR/MMR are still unacceptably high, these programmes should be
accorded top priority, not just as special groups but as key focus running through
the entire policy.
10.4
Health care of the children:
D:\National Health Policy\Review of Drail NHP-99.doc
Page 6 of 14
The focus on 0-2 years must be emphasised and given high priority. They are the
most vulnerable and presently inadequately reached.
10.9
Elderly persons:
-------- Developing geriatric medicine as a distinct specialty with training
programmes as well as promoting care of the Aged Programmes will receive
priority as an investment for the future.
10.10-10.15
Mental Health:
Should be brought under non-communicable section.
There is need to set/accept minimum standards for public/private health centres
and institutions e.g. standards for mental hospitals have been accepted by central
mental health authorities.
10.12 The pilot community mental health programme under implementation should be
expanded after adequate evaluation and assessment.
Tobacco/ Alcohol:
Should be brought under or after Mental Health, as a separate section, but also to
highlight the important risks to mental health as addictions.
10 16 Dental Health:
Training of paramedical dental worker should be mentioned. Also there is need
for a community based and oriented dental service extension programme.
HMIS
11.7
Self recording blood pressure instruments are incongruous in a section on HMIS,
apart from probably being a response to some medical technology lobby. Are
they really needed? Why self recording?
Hand held electronic data entry machine need to be clarified. For what purpose?
Is this another lobby? Both technologies are not high priority.
Private sector regulation:
12.6
-------- The Medical, Nursing and Dental Councils will be enjoined to play a more
effective role in checking the unethical aspects of private practice including over
pricing and profiteering at the cost of the ignorant consumers. The pricing policy
of each centre/ institution could be exhibited or easily accessible to the user.
12.9
Social responsibility of industry:
D:\National Health Policy\Review ofDraftNHP-99.doc
Page 7 of 14
While promoting social responsibility in private and corporate sector is an
important step forward, increased emphasis on quality control accountability and
transparency in government public sector must also be emphasised.
12.9
---- This sector should also be encouraged to be more actively involved in public
health programmes especially all the National Health Programmes.
13.
Medical Education:
Medical education must be need based and community oriented. So policy of
growth and development must emphasise this.
13.4.1 Schemes to encourage medical graduates to go to rural areas
government hospitals and or rural practice will be evolved.
to work in
13.11 Humanpower Resource Development:
The focus on NHP has been on Doctors and Nurses and some allied heath
professionals. No mention of male and female health workers, traditional birth
attendants, anganwadi workers, community based health workers, school
teachers etc. who form the main basis of primary health care. This should be
given a separate section.
13.11.1 There will be a separate body to look into manpower utilization in all health
departments. All vacancies should be filled up to strengthen the health
department.
13.11.1 All medical teachers shall be full time and non-practicing and will be encouraged
to undertake research work. They shall be given appropriate compensatory non
practicing allowances.
13.12.1 Admissions to all courses in medicine and health sciences will be on merit and
through common entrance examinations.
Medical Education:
14.
Some additional policy recommendations:
a)
Teacher training should be made compulsory for all medical college teachers.
There will be one institute in every state, that shall be strengthened to be an
academic staff college, for training teachers for health professional institutions.
All staff posted for training should be supported on official duty basis.
D:\National Health Po)icy\Review of Draft NHP-99.doc
Page 8 of 14
b)
16.
Reform of the existing examination system: is a need of the hour especially
since it has been subject to all types of manipulation and corruption, The
measures to establish quality control in medical education should include:
For MBBS, a grading system (like NCERT has recently introduced for Std
(i)
X at school level) may be introduced. This will include periodic
assessment and final certification with a grade instead of markings.
More
weightage for internal, concurrent assessment and less weightage for
(ii)
external, terminal, passing out examinations.
(iii)
Stricter control over manipulation and unethical practices in the system. If
necessary by open viva voce/clinical evaluation.
Medical Research:
There is need to state that Ethical Guidelines for Medical Research recently
formulated by the 1CMR under the chairmanship of Justice Venkatachalaiah,
Chairman, National Human Rights Commission should be strictly adhered to by
all researchers in the country. There is also need to constantly monitor this and
revise and update the guidelines from time to time.
Epidemiological Research units should be promoted in all medical colleges.
Research as a skill in the education training of all health personnel must be
emphasised. This must emphasise critical reflection on existing practice, existing
experience, existing data as a method of quality improvement.
16.2
Externally aided projects:
There is need to critically assess the role/impact of externally aided projects
especially large loans and grants on public health and primary health care
programmes in the country. Are they enhancing eftectivity, outreach, equity or
are they distorting the system?
Health Education:
This needs to be emphasised and mentioned under a separate section and also re
emphasised in every relevant section.
(To be added after the section on Policy on Indian Systems and Homeopathy)
18.5
Local Health Traditions:
Situation: The people's health culture includes widespread eco-system specific
and ethnic community specific "oral" health traditions. These traditions use over
D:\National Health PolicyVReview of Draft NHP-99.doc
Page 9 of 14
8000 species of plants for health care. Local health traditions include herbal
healers, bone setters, traditional birth attendants, visha vaidyas, etc. and are
estimated to be over a million in the villages in India. There are also several
hundred million rural household traditions of home remedies and local
knowledge, related to food and nutrition.
Policy:
These oral health traditions need to be recognized and revitalized through
i)
suitably designed programmes as a measure for strengthening public
health education and encouraging self-reliance in primary health care in
rural India.
These biological resources and the intellectual property rights (IPR) of
ii)
local communities need to be protected from bio-piracy.
D:\National Health Policy\Review of Draft NHP-99.doc
Page 10 of 14
C)
A Comparative Analysis of NHP-83 and NHP-99 (Draft)
1.
Historical Context:
The NHP-83 was announced against the historical background of the Srivastava
Report (1974); the Alma Ata Declaration on Primary Health Care and Health for
All by 2000 AD, to which India was both a major contributor and an enthusiastic
signatory (1978); the ICSSR-ICMR Health for All Report (1981); and the
populist politics of the early 80's which led to the evolution of the 20-point
programme in which some health issues were key components.
On the other hand the Draft NHP-99 should be contextualised against the
background of the Structural Adjustment Programme of the 1990s leading to New
Economic policies favouring Liberalization, Privatization and Globalization; the
emergence of World Bank as an important funder of Health programmes; and the
gradual shift from health budget increases to increased loans for vertical disease
control programmes. All this situated in the context of the constitutional
amendment for greater de-centralization and Panchayatraj, and the coalition
politics of the 1990s, balancing different interest groups and lobbies.
2.
Successes Identified:
The successes identified by NHP-83 were eradication of smallpox and plague; the
reduction in the problem of Malaria and Cholera; the reduction in Mortality rates
(27.4 to 14.8); the increase in life expectancy (32.7 to 52); the massive increase
in network in health care; the increase in the stock of trained health humanpower;
and the increased indigenous capacity in production of drugs, vaccines and
equipment as a sign of self-reliance.
The NHP-99 highlights the successes as the reduction of birth rates, death rates
and IMR; the substantial increase in immunization rates — BCG-96%, TT-80%,
DPT-90%, Measles-88%; the pulse-polio programme; the reduction in leprosy;
the eradication of guinea worm infection; and some success in the cataract
blindness programme.
3.
The concerns:
The concerns shared in NHP-83 included the continuing population growth; the
unacceptably high mortality rates for women and children; the high IMR; the
continuing malnutrition problem; the continuing high rates of leprosy, TB and
blindness; the problem of access to water supply (only 31% have access); the
problem of access to sanitation (only 0.5% have access); the high rates of
diarrhoeal diseases; and the poor environmental sanitation.
The most significantfeature of the NHP-83 was the powerful historical analysis
which blamed the curative hospital based models of response which neglected
Primary Health Care; increased; and continued the cultural gap in the
D:\Nationai Health Policy\Review of Draft NHP-99.doc
Page 11 of 14
training of health humanpoyver. The NHP-83 also acknowledged poverty and
ignorance as the main cause of continuing ill health.
The NHP-99 on the other hand is concerned about the re-emergence of Plague,
Dengue and Malaria; the emergence of AIDS and Hepatitis; the continuing
nutritional deficiencies; the increase in non-communicable diseases like cancer,
diabetes and CVS disorders; and the problem of contaminated water and
environmental pollution.
It does however mention ill planned urbanization; persistent gaps in manpower;
sub-optimal referral systems; inter-state differences; lack of diagnostic and
treatment manpower; and such techno-managerial factors.
It mentions in passing the increase in environmental and societal problems but
concedes that technical advances have been denied to most of the population due
to lack of resource; lack of awareness; lack of services; and lack of a rights'
perspective.
4.
Challenges/ Approaches:
NHP-83 emphasizes the universal provision of Primary Health Care; the need to
overhaul approaches to training and education; the need to reorganize health
services infrastructure; the relationship of health to development, including
agriculture, food production, rural development, education and social welfare,
housing and water supply and sanitation, and the need for a Drug/Pharmaceutical
policy.
The NHP-99 on the other hand emphasizes the need to reduce inter-state
disparities and differentials; the devolution of authority to Panchayatraj
(decentralization — the need to make primary health services more responsive to
community needs); the need to restructure the existing systems using cost,
participation and result orientation as key factors; and the need to evolve
appropriate policies within the constraints of poverty and illiteracy.
5.
The New Areas:
The NHP-83 particularly highlighted the health issues that had been included in
the 20-point programme.
NHP-99 on the other hand has emphasized the partnerships with the private
sector; other systems of medicine; the role of media, civil society and judiciary;
the need to look critically at health finances and insurance; the aged; the need for
health impact assessment of large development programmes; and also mentions
the need to study the impact of economic policies on health.
Overall the NHP-99 draft policy represents a major shift from NHP-83 in some
significant ways:
D:\National Health Policy\Rcview of Draft NHP-99.doc
Page 12 of 14
i)
ii)
iii)
iv)
V)
The increasing verticalisation of health programmes.
A greater shift to techno-managerialism from earlier attempts to focus on a
more comprehensive socio-economic-political cultural problem analysis.
A change of focus from vulnerable groups to specific disease problems.
A greater adhocism in plan formulation responding to market economy,
lobbies and funding agency driven agendas rather than a more
comprehensive evidence based National planning.
A reduction in overall emphasis on the determinants of health and public
health approaches to programme planning. However, there are some
significant positive trends in comparison to NHP-83 particularly.
The Rights perspective in Health is emphasized.
(a)
The private sector is increasingly recognized in the policy context
(b)
with greater emphasis on its regulation and quality control.
The Indian Systems of Medicine are given more emphasis though
(c)
the policy is just evolving.
Source: Community Health Cell, Bangalore
367, 'Srinivasa Nilaya'
Jakkasandra I Main
I Block Koramangala
Bangalore 560 034
Tel:
080-5531518
Telefax:
080-5525372
Email:
sochara@vsnl.com
Date:
28 April, 2000
D:\National Health Policy\Review of Draft NHP-99.doc
Page 13 of 14
Appendix I
Participants of the Dialogue on NHP-99 Draft Policy
Document on 15.3.2000 at KHSDP Office
(Some areas of interest/expertise shown in brackets)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Dr. C.M. Francis, Consultant, Community Health Cell and Member Karnataka Task Force in
Health. Chairperson. (Health Management, Ethics, Law).
Dr. D.K. Srinivasa, Medical Education Consultant, Rajiv Gandhi University of Health Sciences.
Karnataka. (Community Medicine, Health Humanpower Development.)
Dr. Ramesh Billimagga, President Elect, Indian Medical Association, Karnataka Chapter.
(Clinical Medicine, Oncology).
Dr. H. Sudarshan, Director VGKK, BR Hills and Chairperson, Karnataka Task Force in Health.
(Community Health, MCH, NGO, People's Empowerment).
Dr. Thelma Narayan, Coordinator, Community Health Cell. Bangalore and Member, Karnataka
Task Force in Health. (Epidemiology, Public Health Policy).
Dr. M.K. Sudarshan, Principal, Kempegowda Institute of Medical Sciences and Head of the
Department of Community Medicine. (Community Medicine, Communicable Diseases).
Dr. Mohan Isaac, Professor and Head of the Department of Psychiatry, National Institute of
Mental Health and Neuro Sciences, Bangalore. (Mental Health).
Dr. Latha Jagannathan, Director TTK Blood Bank, Bangalore and Member, Karnataka Task Force
in Health and CII Committee on Social Responsibility of Corporate Sector.
(MCH, NGOs, Private Sector).
Ms Padmasini Asuri, Retired Nutritionist and Regional Home Economist, Government of India.
and DANIDA Consultant, Women and Agriculture. (Nutrition, Women's Health).
Dr. Ramesh Kanbargi, Demographer, Institute for Social and Economic Change, Bangalore.
(Demography & Population Policy, Decentralization).
Dr. S.K. Ghosh, Officer in Charge, Malaria Research Centre (Indian Council of Medical Research)
Bangalore. (Research, Vector Borne Diseases)
Dr. Tiwari, Research Officer, Malaria Research Centre (ICMR) Bangalore.
(Vector Borne Diseases, Community Participation).
Dr. Nagabhushan, Professor of Department of Medicine, Government Medical College,
Bangalore. (Clinical Medicine, Ethics, Medical Education).
Dr. S. Pruthvish, Coordinator, Disability Unit, Action Aid, Bangalore.
(Community Medicine, CBR, Public Health).
Mr. As Mohamed. Asst. Professor. Statistics & Demography, Department of Community Health,
St John's Medical College, Bangalore. (Demography, Statistics, HMIS, Population Policy).
Dr. Ravi Narayan, Community Health Advisor, Community Health Cell, Bangalore
(Public Health, Industrial Health, Medical Education).
Dr. James Parayil Joseph, Consultant Dermatology, STD/Leprology, Research Associate.
Community Health Cell, Bangalore.
Mr. S.D. Rajendran, Research Assistant, Community Health Cell, Bangalore.
Mr. A. Prahlad, Training Assistant, Community Health Cell, Bangalore.
Mr. S.J. Chander, Medical Social Worker, Bangalore.
Sent comments hut could not attend:
21.
22.
23.
Dr. R.L. Kapur, Consultant, Psychiatrist and Social Science Research. Community Health Cell,
Bangalore. (Community Mental Health, Social Sciences, Research).
Mr. Darshan Shankar, Director, Foundation for Revitalization of Local Health Traditions,
Bangalore. (Folk Medicine, Indian Systems of Medicine).
Dr. Pankaj Mehta, Professor & Head, Department of Community Medicine and Vice Dean,
Manipal Hospital, Bangalore. (Community Medicine, Public Health).
D:\National Health Policy\Review of Draft NHP-99.doc
Page 14 of 14
Hp
C.H.C'S response to Dr.K.K.Datta's request for views on policy issues for
Health Policy document dated 10th April 2000.
SOME REFLECTIONS ON CRITICAL ISSUES FOR THE NATIONAL
HEALTH POLICY
1. Vertical Vs Horizontal Implementation.
This has been a dilemma for health policy and health programme planners
for a long time and we do not go too much into the dialectics and
semantics. However the policy position of NHP could consist of the
following in this context.
i.
While the focus has to be on Primary Health Care, the overall policy
should support strengthening of health care services at every level primary, secondary and tertiary and integrating every new programme
or initiative within the existing functioning of the service at that level
and within the existing job responsibilities and framework of operations
of staff at each level.
Horizontal integration must be the overriding policy as in NTP
and Mental Health in the past.
ii.
Some health problems - be they focussed on specific diseases or
vulnerable groups etc may require a special focus with an element of
verticality because of
a)
Magnitude of the problem
b)
Urgency of the response
c)
Need to ensure quality of operations
d)
Complexity of the initiative including training aspects.
However while this may be a short term goal it should be built into a
scheme of full integration.
Specific initiatives that may seem
vertical at first may be the starting points for building structures,
systems, framework of action on which other programme
initiatives could piggy back in the future e g. While EPI may have
sometimes required some degrees of verticality in some stages the
whole framework of operations and linkages can be used for
tackling other programmes as a sustained operation.
Vertical programme if available should be need based or problem
specific as a symbol of priority setting but not dictated by funding
agency conditionalities, market factors, magic bullet approaches or the
result of lobbies that promote technological fixes.
D:'National Health Policy\CHCs Response to Dr. K.K. Datta.doc
-1 -
Horizontal Vs Vertical is not the issue. When vertical and when
horizontal, and how these approaches can be integrated in a
continumm is the issue.
2. Decentralization
Different people understand Decentralization differently.
i.
Delegating the administrative and financial powers to lower
levels.
The Decentralization is within the health system.
Responsibility and authority are delegated to lower levels and to the
periphery, quicker decisions can be taken and the problems can be
tackled at the lower levels.
ii.
Empowering the people to take decisions and act locally. Here
there is transfer of political power to the lower levels- from the centre
to the state to the district to the Panchayat and ultimately to the Gram
Sabha.
iii.
Such political and economic Decentralization requires enabling of the
people, making them competent to discharge their duties and
responsibilities while exercising their authority and privileges.
Collaboration with qualifed and trained persons (official and non
official) can help in this process of identifying and prioritization of
problems, working out feasible plans, their implementation, monitoring
and evaluation.
We believe that all these types of decentralization should be
promoted in the Health Policy.
3. Policy for Private Sector
In Health Care Services, the Private Sector is much larger than the Public
Sector. The Private Sector is not homogeneous. There are different
players:
i.
Private, not-for-profit or voluntary sector. The Organizations are
motivated by altruistic or philanthropic motives. They may belong to
different groups and philosophies: Gandhian, Marxist, Sarvodaya,
Religious and others.
They may be organized as Registered
Societies, Trusts or Companies.
ii.
Private, for-profit sector.
Individual practitioners constitute the
largest number. There are nursing homes, private hospitals, and
corporate hospitals. In recent times, the corporate hospitals are
dominant. They provide mostly tertiary care.
iii.
There are co-operative hospitals and group practices. They are
not very prominent.
D:\National Health Policy\CHC's Response to Dr. K.K. Datta.doc
-2-
There is need for a policy of partnership between the private sector
and public sector.
The Private Sector needs some regulation to assure quality of care. The
ideal is self-regulation by the institutions and professionals, maintaining
appropriate standards: structure, process and outcome. The Government
should be both regulatory and facilitatory (Helping the institutions and
professionals by training and other means).
There has to be transparency in all dealings. A process of accreditation
helps!
The National Health Policy for Private Sector must therefore include
policy for appropriate standard settings; regulation, accreditation
and facilitation and monitoring.
4. Inadequate Resources and Under-funding
The resources, whether human, material or financial, are inadequate. The
resources are also unevenly distributed with differences - region wise,
rural Vs urban, affluent Vs poor. There is need to increase the
resources and allocations and, while doing so, to pay special
attention to the backward regions and to the underserved people.
The budget allocations are totally inadequate, both with respect to the
needs and what is being made available in other countries. There is need
to ensure 5% allocation for health services at the centre and 15% at
the state. This must be achieved progressively. There is under-utilization
of the allotted resources, large chunks of the finances are surrendered at
the end of the year. Poor financial achievement is paralleled by poor
physical achievements. There is no proper management of the resources.
The Policy must include
i) Adequate resource allocation ii)
Attention to resources allocation in the context of equity and regional
disparities Hi) Accountable and transparent financial management
iv) Regular financial and social audit v) Training of key health
personnel in financial management.
5. Quality Control
Quality assurance is a must. We have to define appropriate standards of
structure (what we put in or what is available), process (what we do and
how we do it) and the outcome (result). Outcome would include patient
satisfaction.
There is urgent need to evolve a process of Quality Assurance
beginning with quality standards setting for all levels of health care.
D '. 'National Health Policy\CHCs Response to Dr. K.K. Datta.doc
-3-
6. Consumer Protection
Major drawbacks in Health Care are as a result of negligence and
incompetence. There is a duty of care which every health professional
and health care institution must adhere to.
The Consumer Protection Act is expected to help the consumer (the
client). There are two parts: the councils which are to spread the
information about the rights of the patients and the grievance redressal
forums. The latter has been active. The former has not been adequately
addressed.
There is need for certain amendments to the Consumer Protection Act to
make it more effective and at the same time reduce the possibilities of
harassment.
The NHP should clearly mention the CPA and its implications and
make provisions for awareness building on rights of patients, as well
as facilitating adequate and effective grievance redressal forums.
7. Use of Technology
Advances are taking place at a fast pace in the Medical Science and
Technology. Not all advances in technology are assessed adequately.
Many are used prematurely.
Some technologies are misused. One example is the prenatal sex
determination and female foeticide following it. More common examples
are the unethical promotion of drugs and their unwanted use.
The NHP must clearly state a medical technology policy that clarifies
the context and goal of technology introduction to promote equity,
access quality, efficiency, relevance and effectivity in Health Care at
different levels. Introduction of technology should not be due to
market economy factors as well as the result of aggressive lobbies
by manufacturers.
8. Drugs and Modern Medicine vis-d-vis Traditional Medicine
Fast developments are taking place in the field of medicines. They are
protected by patents for a period of time. The firms want to make quick
profits and promote them without adequate evidence of their utility.
There are many traditional medicines : Systematic as in Ayurveda, Unani,
Siddha and Homeopathy and folk medicine, often disseminated in the oral
tradition. These traditional medicines have withstood the test of time.
They may not have been submitted to double-blind studies or the
conventional tests; these may not even be appropriate. But there is need
to determine the efficiency of the drugs and ensure that they do not harm:
D:'National Health Policy'CHCs Response to Dr. K.K. Datta.doc
-4-
beneficence and non-maleficence. Once that is determined, the choice
has to be with the patients, respecting autonomy.
The National Health Policy should now take a strong medically plural
stand - recognizing respecting, supporting and promoting all
systems and approaches of health care that have evolved
systematically and have both technical and peoples acceptance. The
Policy should not be “this Vs that” but more integrated and inclusive
policies that recognise Medical pluralism and the patients' autonomy
in making choices.
9. Manpower Planning
Our Manpower planning leaves a lot to be desired. There is need to
determine the needs and resources.
Health human resources
development needs strategic planning which must be appropriate to the
needs of the people and relevant to the region
,
Manpower planning must include all categories of health professionals and
health workers ( paramedical).
NHP must address Health human power Development as a total,
integrated issue by the setting up of National commission to make a
comprehensive assessment of needs, availability, norms and
educational systems/training programmes to achieve the goals.
Leaving each council to function independently and in isolation
needs to be reviewed. The commission must involve all councils but
be able to see the larger health team context and the required ‘mix’
as well at all levels.
(
f
CHC
D:\National Health Policy\CHC's Response to Dr. K.K. Datta.doc
-5-
Hr. SJ- Cl
HP'2-
A Review Meeting on the Draft NHP-99 Document
An interactive participatory dialogue was held at KHSDP Office (Public Health Institute)
on the draft National Health Policy-1999 (Government of India-Ministry of Health and
Family Welfare). The meeting was facilitated by Community Health Cell (CHC)
Bangalore at the initiative of Dr H. Sudarshan, Chairperson of the Karnataka Task Force
in Health. The meeting brought together about 20 resource persons representing different
disciplines and sectors so that the policy document could be reviewed from various
angles. These disciplines included Public Health, Community Medicine, Clinical
Medicine, Demography and Statistics, Management, Nutrition, Social Sciences, Mental
Health, Research, Health Humanpower Development and so on (see list in Appendix I for
further details).
All the participants had received a copy of the draft policy document and had come very
well prepared so the meeting brought together a wealth of ideas, perspectives and
suggestions. We hope the policy formulators will take these suggestions in the spirit of
solidarity in which they are shared.
The minutes are compiled into the following sections:
A)
B)
C)
The comments on the overall framework of the document.
Additions, lacunae or omissions in the document including suggestions for re
wording, re-orienting or re-integrating parts of the document. This is presented in
the chronology of sub-headings in the draft document and the relevant paragraph
number pertaining to draft policy document.
Comparison was also attempted between NHP-83 and draft NHP-99 and this is
enclosed as an appendix.
A)
General comments:
i)
The document is not well integrated. It is not clear whether it is a policy
document, a programme document, a plan of action or all put together.
The language is very variable, quite uninspiring and varying in quality. It seems
to be many different contributions put together, unedited.
Editing needs to be done, effectively keeping the language crisp, brief, readable
and formatted in an attractive way, with headings and sub-headings that make
perusal interesting.
Some places the wording is apologetic and in some places there is far too much
detail for a policy document.
There is no sense of priority and all issues seem to be given same importance
even though magnitude, relevance, impact or need may be very different.
In many places the statements are ambiguous, not specific. There is need for
clarity and specifics.
ii)
iii)
iv)
v)
vi)
D:\Ntfional HcaM> Policr Jteview of Draft NHP-99 doc
Page 1 of 15
vii)
Considering this is only a draft document some of the above may be accepted as
part of an evolutionary process but a logical framework and professional
presentation is definitely required.
The document should have:
A Preamble—
(a)
A situation analysis
(b)
(c)
(d)
(e)
(f)
B)
1.10
2.1
why NHP-2000.
The health situation.
The successes or failures of NHP-83 (including
where we are in the goals indicated at the end of
NHP-83 document) and why this is so.
The Vision/ Mission - Policy of Government in 1999-2000.
Then all the sub-sections in the present document - slightly integrated or
re-arranged.
The goals of the policy, the monitoring-evaluation policy and mechanism
by which the policy is renewed/reviewed through action and evidence.
The Health Policy document should be a comprehensive one, so that the
other policies related to health -- be in population; drug; blood bank;
nutrition policy; health human power development; AIDS control; should
be integrated into it.
Some Concerns: (only key concerns shared in the meeting are included)
Decentralization:
In spite of increasing overall commitment (Item 1.10 of draft NHP-99) to
i)
develop models to show how Panchayati Raj institutions (PRI) can be
made responsible for rural health care institutions, there is a tendency to
promote District level single health problem focussed societies for TB,
AIDS etc. which contradicts this commitment . This distortion must be
reviewed urgently.
As a preparation for transfer of decentralized responsibilities to PRIs,
>i)
training of PRI members and leadership in assessing community health
needs and priorities must be done on a high priority basis.
Epidemiological transition:
While epidemiological transition is taking place, it is taking place at different
levels in different classes and there is need to ensure that what affects the 10%
upper class of the population does not overshadow all the priority problems of the
remaining 90% of the population.
2.3
A
The proposed policy for local practitioners to be permitted to pay rent and
practice in PHCs, after OPD hours, is not a very sensible policy since it could lead
to all sorts of distortions and unethical practices. In areas where there is great
need, and the absence of government personnel, this could be experimented with
in the interim/ short term very cautiously.
D:'NMion»i Haith Policy.Review of Daft NHP-99 doc
Page 2 of 15
2.4
The need for establishing a senior focal point at the district level for health, family
welfare and women and child development schemes have been recognized. The
States would be encouraged to set up a district-based hierarchy for overseeing the
implementation of national programmes and public health functions. Persons
with postgraduate qualifications and or training shall be posted for
administrative posts from district level and above.
2.5.1
The State Institute for Health and Family Welfare will be established and
developed as an apex training centre to promote public health, epidemiology and
health management skills at all levels.
3.
Environmental Health: is a very important issue and with increasing pollution
of air, water and soil,, due to indiscriminate and unplanned industrialization;
inadequate waste disposal and pollution control; inadequate monitoring and
control. The health hazards for urban population more specifically and the rural
population more generally, is increasing and needs to be tackled on a priority
basis.
3.4
Add local health traditions to list of traditional pillars.
3.6
Public Health:
Needs to be strongly re-emphasised and also accepted as the primary
responsibility of the government guaranteed constitutionally. Even if partnerships
are evolved with other sectors, the primary responsibility should be with the
government.
Also within public health policy, intersectoral approaches to tackle all the
determinants of health should be included and focus on just a few preventable
diseases with top down vertical programmes should be avoided. Horizontal
integration and intersectoral approach should be clearly emphasised.
3.9
Nutrition: should be a separate section and not a sub-section of Environmental
Health and Sanitation.
3.10
Important to ensure that the new focus on micronutrients should not distract or
distort the overall focus on malnutrition. The basic problem is food available in
the diet, not absence of zinc or iodine by themselves. This will ensure focus on
broader issues of Nutrition and food security including:
Public distribution system
a)
Availability of adequate cereals and pulses
b)
Importance of kitchen gardens
c)
3.12
The public distribution system and nutrition of people have a close intersectoral
link and this interphase should be mentioned and the focus not only on increased
D:\NMionai Health PoliqAReview of Draft NHP-99.doc
Page 3 of 15
o
■
food security (as agricultural policy) but also access to adequate food - nutrition
security (as Health policy) should be clearly stated.
Role of School Health and Nutrition education programmes must be mentioned
specifically.
Importance of nutrition in health needs greater emphasis in education/training of
all health personnel.
4.2
Tuberculosis: Since RNTCP will take a decade to spread over the whole
country, there is need to mention NTP and its strengthening, not just RNTCP.
4.3
Leprosy: There is need to continue to stress survey education and training (SET)
and to detect and treat effectively without letting the success of MDT overshadow
the reality.
4.4
AIDS Control Policy:
Home based care and strengthening skills of careers at this level must be an
important focus and component.
The exceptions that have been allowed in the Blood Bank policy for the army
medical units may be considered for certified/registered units in rural/tribal and
remote areas ro enhance access and availability of blood for the poor.
Draft National Blood Banking Policy (In Summary)
4.5
The Draft blood banking policy while setting quality standards must reconsider
peripheral health centres and field situations where collection can still be done, to
help access to blood for poorer and more marginalised sections of the community.
4.6
Malaria
4.6
Vector Borne Diseases:
Vector borne diseases like Malaria, Filaria and Dengue are rampant all over the
country. In addition, Japanese Encephalitis, KFD and Kalazar are also prevalent
in specific pockets in the country. These diseases cause high mortality, therefore
all of them should be notifiable and special bye-laws should be made applicable
to all these vector borne diseases.
Selective and location specific vector control is the right approach. Bioenvironmental control which is eco-friendly, sustainable, high cost effective
should be given top priority for long term sustainable control strategies.
The involvement of the community in the prevention and control of vector borne
diseases will be given the strongest emphasis with the aim of eliminating
mosquito breeding through active health education and community participation.
D:\N*ional Health PolicyJleview of Draft NHP-99.doc
Page 4 of 15
4.7.1
Malaria (as in 4.6 in draft document)
4.8.2
Filariasis (as in 4.7 in draft document)
4.9.3
Dengue (as in 4.8 in draft document)
4.10
Kalazar. This is restricted mostly to parts of Bihar. More intensive action
research and efforts to provide curative, preventive and promotive care to the
affected people must be made.
4.11
KFD is only restricted to a small pocket in Karnataka. Proper efforts should be
made to eliminate this disease from this pocket through adequate and relevant
public health measures.
4.12
Japanese encephalitis must be mentioned.
4.13
There is adequate information on the vectors and their biology in the country.
Posts of medical entomologists will be created at district levels. These posts will
be at the senior scientist level. Recruitment of such posts will be made strictly on
merit.
5.4
Backlog of cases with cataract related blindness may still need a camp approach
so setting quality standards for camps may be better than phasing out.
5.7-5 9 Persons with Disabilities:
All aspects of the Disabilities Act need to be highlighted , not only prevention.
National disability rehabilitation plan needs to be mentioned.
School health as a forum to prioritise and address problems of differently abled
children.
CBR should be promoted in the curriculum of all health personnel at all levels.
(When the health policy speaks about involving any other partner from NGO
sector, private sector, corporate sector, GPs, traditional medicine sector, folk
sector etc. the word ’’used" should be changed to "involved" or "enhance
collaboration with" in the true sense of partnership).
5.8
In disability section - medical aspects should also be highlighted and the need for
enhancing skills in physiotherapy and occupational therapy in the health team in
general apart from enhancing training for allied health professionals, and
therapists in particular, should be emphasised.
6.
Drug Policy:
D:'NM»on»J Haith Policy'Rzview of Drafl NHP-99.doc
Page 5 of 15
a)
The goal and emphasis on self reliance in drugs and vaccine production
should be emphasised and drug policy should promote this proactively.
b)
The indigenous production of testing kits for Hepatitis 'C and HIV/AIDS
will be encouraged. There should be increased emphasis on rational
prescription practices, and CUE for practitioners on Rational Drug use
should be encouraged in association with professional associations and
medical colleges.
6.9
---------Likewise enhancing the production of purified rabies immunoglobulin
and their wider use will be permitted.
8.
Trauma and Emergency Services:
While the focus on trauma /accident is an important one - there is need to
include
emergency service focus on two other important and common
emergencies:
Obstetrical emergencies
a)
b)
Snake bites. Steps to increases effective response to these must be taken.
8.3
(reworded)
(i)
Disaster preparedness — Response and rehabilitation plans should be drawn up at
the National and State levels.
Large government and private hospitals should have contingency plans for
management of mass casualties.
Adequate resources should be made available for, (i) and (ii) including through
involvement of private and NGO hospitals and who volunteers to treat victims of
accidents and disasters.
Training in disaster preparedness for doctors and other health professionals should
be organized regularly.
(ii)
(iii)
(iv)
10.1-10.3
Health of Women and
10.4-10.8
Health of Children
Since IMR/MMR are still unacceptably high, these programmes should be
accorded top priority, not just as special groups but as key focus running through
the entire policy.
10.4
Health care of the children:
D:'NMJon«l Health PolicyxReview of Draft NHP-99.doc
Page 6 of 15
The focus on 0-2 years must be emphasised and given high priority. They are the
most vulnerable and presently inadequately reached.
10.9
Elderly persons:
-------- Developing geriatric medicine as a distinct specialty with training
programmes as well as promoting care of the Aged Programmes will receive
priority as an investment for the future.
10.10-10.15
Mental Health:
Should be brought under non-communicable section.
There is need to set/accept minimum standards for public/private health centres
and institutions e.g. standards for mental hospitals have been accepted by central
mental health authorities.
10.12 The pilot community mental health programme under implementation should be
expanded after adequate evaluation and assessment.
Tobacco/ Alcohol:
Should be brought under or after Mental Health, as a separate section, but also to
highlight the important risks to mental health as addictions.
10.16 Dental Health:
Training of paramedical dental worker should be mentioned. Also there is need
for a community based and oriented dental service extension programme.
HMIS
11.7
Self recording blood pressure instruments are incongruous in a section on HMIS,
apart from probably being a response to some medical technology lobby. Are
they really needed? Why self recording?
Hand held electronic data entry machine need to be clarified. For what purpose?
Is this another lobby? Both technologies are not high priority.
Private sector regulation:
12.6
---------The Medical, Nursing and Dental Councils will be enjoined to play a more
effective role in checking the unethical aspects of private practice including over
pricing and profiteering at the cost of the ignorant consumers. The pricing policy
of each centre/ institution could be exhibited or easily accessible to the user.
12.9
Social responsibility of industry:
D:'NMional Health PobcySReview ofDnfi NHP-99 doc
Page 7 of 15
While promoting social responsibility in private and corporate sector is an
important step forward, increased emphasis on quality control accountability and
transparency in government public sector must also be emphasised.
12.9
■This sector should also be encouraged to be more actively involved in public
health programmes especially all the National Health Programmes.
13.
Medical Education:
Medical education must be need based and community oriented,
growth and development must emphasise this.
So policy of
13.4.1 Schemes to encourage medical graduates to go to rural areas
government hospitals and or rural practice will be evolved.
to work in
13.11 Humanpower Resource Development:
The focus on NHP has been on Doctors and Nurses and some allied heath
professionals. No mention of male and female health workers, traditional birth
attendants, anganwadi workers, community based health workers, school
teachers etc. who form the main basis of primary health care. This should be
given a separate section.
13.11.1 There will be a separate body to look into manpower utilization in all health
departments,
All vacancies should be filled up to strengthen the health
department.
13.11.1 All medical teachers shall be full time and non-practicing and will be encouraged
to undertake research work. They shall be given appropriate compensatory non
practicing allowances.
13.12.1 Admissions to all courses in medicine and health sciences will be on merit and
through common entrance examinations.
14.
Medical Education:
Some additional policy recommendations:
a)
Teacher training should be made compulsory for all medical college teachers.
There will be one institute in every state, that shall be strengthened to be an
academic staff college, for training teachers for health professional institutions.
All staff posted for training should be supported on official duty basis.
D:\NMiocaJ Health PoiicrJlmew of Drift NHP-99 doc
Page 8 of 15
b)
16.
Reform of the existing examination system: is a need of the hour especially
since it has been subject to all types of manipulation and corruption, The
measures to establish quality control in medical education should include:
For MBBS, a grading system (like NCERT has recently introduced for Std
(0
X at school level) may be introduced. This will include periodic
assessment and final certification with a grade instead of markings.
More
weightage for internal, concurrent assessment and less weightage for
(ii)
external, terminal, passing out examinations.
(iii)
Stricter control over manipulation and unethical practices in the system. If
necessary by open viva voce/clinical evaluation.
Medical Research:
There is need to state that Ethical Guidelines for Medical Research recently
formulated by the ICMR under the chairmanship of Justice Venkatachalaiah,
Chairman, National Human Rights Commission should be strictly adhered to by
all researchers in the country. There is also need to constantly monitor this and
revise and update the guidelines from time to time.
Epidemiological Research units should be promoted in all medical colleges.
Research as a skill in the education training of all health personnel must be
emphasised. This must emphasise critical reflection on existing practice, existing
experience, existing data as a method of quality improvement.
16.2
Externally aided projects:
There is need to critically assess the role/impact of externally aided projects
especially large loans and grants on public health and primary health care
programmes in the country. Are they enhancing effectivity, outreach, equity or
are they distorting the system?
Health Education:
This needs to be emphasised and mentioned under a separate section and also re
emphasised in every relevant section.
(To be added after the section on Policy on Indian Systems and Homeopathy)
18.5
Local Health Traditions:
Situation: The people's health culture includes widespread eco-system specific
and ethnic community specific "oral" health traditions. These traditions use over
Health Policy*.Review of Draft NHP-99.doc
Page 9 of 15
8000 species of plants for health care. Local health traditions include herbal
healers, bone setters, traditional birth attendants, visha vaidyas, etc. and are
estimated to be over a million in the villages in India. There are also several
hundred million rural household traditions of home remedies and local
knowledge, related to food and nutrition.
Policy:
These oral health traditions need to be recognized and revitalized through
i)
suitably designed programmes as a measure for strengthening public
health education and encouraging self-reliance in primary health care in
rural India.
These biological resources and the intellectual property rights (IPR) of
ii)
local communities need to be protected from bio-piracy.
D:\NMional Health Policy*Jlevtew of Draft NHP-99.doc
Page 10 of 15
C)
A Comparative Analysis of NHP-83 and NHP-99 (Draft)
1.
Historical Context:
The NHP-83 was announced against the historical background of the Srivastava
Report (1974); the Alma Ata Declaration on Primary Health Care and Health for
All by 2000 AD, to which India was both a major contributor and an enthusiastic
signatory (1978); the ICSSR-ICMR Health for All Report (1981); and the
populist politics of the early 80's which led to the evolution of the 20-point
programme in which some health issues were key components.
On the other hand the Draft NHP-99 should be contextualised against the
background of the Structural Adjustment Programme of the 1990s leading to New
Economic policies favouring Liberalization, Privatization and Globalization; the
emergence of World Bank as an important funder of Health programmes; and the
gradual shift from health budget increases to increased loans for vertical disease
control programmes. All this situated in the context of the constitutional
amendment for greater de-centralization and Panchayatraj, and the coalition
politics of the 1990s, balancing different interest groups and lobbies.
2.
Successes Identified:
The successes identified by NHP-83 were eradication of smallpox and plague; the
reduction in the problem of Malaria and Cholera; the reduction in Mortality rates
(27.4 to 14.8); the increase in life expectancy (32.7 to 52); the massive increase
in network in health care; the increase in the stock of trained health humanpower;
and the increased indigenous capacity in production of drugs, vaccines and
equipment as a sign of self-reliance.
The NHP-99 highlights the successes as the reduction of birth rates, death rates
and IMR; the substantial increase in immunization rates — BCG-96%, TT-80%,
DPT-90%, Measles-88%; the pulse-polio programme; the reduction in leprosy;
the eradication of guinea worm infection; and some success in the cataract
blindness programme.
3.
The concerns:
The concerns shared in NHP-83 included the continuing population growth; the
unacceptably high mortality rates for women and children; the high IMR; the
continuing malnutrition problem; the continuing high rates of leprosy, TB and
blindness; the problem of access to water supply (only 31% have access); the
problem of access to sanitation (only 0.5% have access); the high rates of
diarrhoeal diseases; and the poor environmental sanitation.
The most significantfeature of the NHP-83 was the powerful historical analysis
which blamed the curative hospital based models of response which neglected
Primary Health Care; increased; and continued the cultural gap in the
D:\NMjora4 Health Polky Review of Draft NHP-99.doc
Page 11 of 15
training of health humanpower. The NHP-83 also acknowledged poverty and
ignorance as the main cause of continuing ill health.
The NHP-99 on the other hand is concerned about the re-emergence of Plague,
Dengue and Malaria; the emergence of AIDS and Hepatitis; the continuing
nutritional deficiencies; the increase in non-communicable diseases like cancer,
diabetes and CVS disorders; and the problem of contaminated water and
environmental pollution.
It does however mention ill planned urbanization; persistent gaps in manpower;
sub-optimal referral systems; inter-state differences; lack of diagnostic and
treatment manpower; and such techno-managerial factors.
It mentions in passing the increase in environmental and societal problems but
concedes that technical advances have been denied to most of the population due
to lack of resource; lack of awareness; lack of services; and lack of a rights'
perspective.
4.
Challenges/ Approaches:
NHP-83 emphasizes the universal provision of Primary Health Care; the need to
overhaul approaches to training and education; the need to reorganize health
services infrastructure; the relationship of health to development, including
agriculture, food production, rural development, education and social welfare,
housing and water supply and sanitation, and the need for a Drug/Pharmaceutical
policy.
The NHP-99 on the other hand emphasizes the need to reduce inter-state
disparities and differentials; the devolution of authority to Panchayatraj
(decentralization - the need to make primary health services more responsive to
community needs); the need to restructure the existing systems using cost,
participation and result orientation as key factors; and the need to evolve
appropriate policies within the constraints of poverty and illiteracy.
5.
The New Areas:
The NHP-83 particularly highlighted the health issues that had been included in
the 20-point programme.
NHP-99 on the other hand has emphasized the partnerships with the private
sector; other systems of medicine; the role of media, civil society and judiciary;
the need to look critically at health finances and insurance; the aged; the need for
health impact assessment of large development programmes; and also mentions
the need to study the impact of economic policies on health.
Overall the NHP-99 draft policy represents a major shift from NHP-83 in some
significant ways:
D:\NMJomi Health PolKyMUview of Draft NHP-99 <toc
Page 12 of 15
i)
ii)
iii)
iv)
V)
The increasing verticalisation of health programmes.
A greater shift to techno-managerialism from earlier attempts to focus on a
more comprehensive socio-economic-political cultural problem analysis.
A change of focus from vulnerable groups to specific disease problems.
A greater adhocism in plan formulation responding to market economy,
lobbies and funding agency driven agendas rather than a more
comprehensive evidence based National planning.
A reduction in overall emphasis on the determinants of health and public
health approaches to programme planning. However, there are some
significant positive trends in comparison to NHP-83 particularly.
The Rights perspective in Health is emphasized.
(a)
The private sector is increasingly recognized in the policy context
(b)
with greater emphasis on its regulation and quality control.
(C)
The Indian Systems of Medicine are given more emphasis though
the policy is just evolving.
Source: Community Health Cell, Bangalore
367, 'Srinivasa Nilaya'
Jakkasandra I Main
I Block Koramangala
Bangalore 560 034
Tel:
080-5531518
Telefax:080-5525372
Email:
sochara@vsnl.com
Date:
28 April. 2000
D:'N*iorud Health Policy\Review of Drift NHP-99.doc
Page 13 of 15
Re? National Health Policy
Subject: Re: National Health Policy
Date: Fri, 28 Apr 2000 16:33:54 +0530
From: Community Health Cell <sochara@vsnl.com>
To: dirnicd@bol.net.in, dirnicd@nda.vsnl.net.in, sujatharao@vsnl.com, vgkk@vsnl.com
To:
Dr K.K Datta, Director NICD
Ms Sujatha Rao, Jt Secy Ministry of Health & Family Welfare
Dr H. Sudarshan
Enclosed are some of our views on the nine issues listed out in Dr
Datta's letter to us dated 10th April 2000.
Also attached is a more detailed document that brings together all the
views, concerns and suggestions on 1
’
-““ Draft Policy document at a
the
NHP-99
meeting we organized in Bangalore a few weeks
---- ; ago. The list of the
participants is enclosed.
Kindly acknowledge receipt of the same. CHC and its associates would be
glad to continue the dialogue on ■any of the issues and views raised in
these documents.
Best wishes and regards,
Dr Thelma Narayan, Co-ordinator
Community Health Cell, Bangalore
P~|CHCs Response to Dr, K.K. Datta.doc
Name: CHC’s Response to Dr. K.K. Datta.doc
Type: Winword File (application/msword)
Encoding: base64
Name: Review of Draft NHP-99.doc
[j Review of Draft NHP-99.doc i
Type: Winword File (application/msword)
j Encoding: base64
1 of!
5/2/00 3:21
Appendix I
Participants of the Dialogue on NHP-99 Draft Policy
Document on 15.3.2000 at KHSDP Office
(Some areas of interest/expertise shown in brackets)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Dr. C.M. Francis, Consultant, Conununity Health Cell and Member Karnataka Task Force in
Health. Chairperson. (Health Management, Ethics, Law).
Dr. D.K. Srinivasa, Medical Education Consultant, Rajiv Gandhi University of Health Sciences.
Karnataka. (Community Medicine, Health Humanpower Development.)
Dr. Ramesh Billimagga, President Elect, Indian Medical Association, Karnataka Chapter.
(Clinical Medicine, Oncology).
Dr. H. Sudarshan. Director VGKK, BR Hills and Chairperson, Karnataka Task Force in Health.
(Community Health, MCH, NGO, People's Empowerment).
Dr. Thelma Narayan, Coordinator, Community Health Cell, Bangalore and Member, Karnataka
Task Force in Health. (Epidemiology, Public Health Policy).
Dr. M.K. Sudarshan, Principal, Kempegowda Institute of Medical Sciences and Head of the
Department of Community Medicine. (Community Medicine, Communicable Diseases).
Dr. Mohan Isaac, Professor and Head of the Department of Psychiatry, National Institute of
Mental Health and Neuro Sciences, Bangalore. (Mental Health).
Dr. Latha Jagannathan, Director TTK Blood Bank, Bangalore and Member, Karnataka Task Force
in Health and CD Committee on Social Responsibility of Corporate Sector.
(MCH, NGOs, Private Sector).
Ms Padmasini Asuri, Retired Nutritionist and Regional Home Economist, Government of India,
and DANIDA Consultant, Women and Agriculture. (Nutrition, Women's Health).
Dr. Ramesh Kanbargi, Demographer, Institute for Social and Economic Change, Bangalore.
(Demography & Population Policy, Decentralization).
Dr. S.K. Ghosh, Officer in Charge, Malaria Research Centre (Indian Council of Medical Research)
Bangalore. (Research, Vector Borne Diseases)
Dr. Tiwari, Research Officer, Malaria Research Centre (ICMR) Bangalore.
(Vector Borne Diseases, Community Participation).
Dr. Nagabhushan, Professor of Department of Medicine, Government Medical College,
Bangalore. (Clinical Medicine, Ethics, Medical Education).
Dr. S. Pruthvish, Coordinator, Disability Unit, Action Aid, Bangalore.
(Community Medicine, CBR, Public Health).
Mr. As Mohamed. Asst. Professor. Statistics & Demography, Department of Community Health,
St John's Medical College, Bangalore. (Demography, Statistics, HMIS, Population Policy).
Dr. Ravi Narayan, Community Health Advisor, Community Health Cell, Bangalore
(Public Health, Industrial Health, Medical Education).
Dr. James Parayil Joseph, Consultant Dermatology, STD/Leprology, Research Associate,
Community Health Cell, Bangalore.
Mr. S.D. Rajendran, Research Assistant, Community Health Cell, Bangalore.
Mr. A Prahlad, Training Assistant, Community Health Cell, Bangalore.
Mr. S.J. Chander, Medical Social Worker, Bangalore.
Sent comments but could not attend:
21.
22.
23.
Dr. R.L. Kapur, Consultant, Psychiatrist and Social Science Research, Community Health Cell,
Bangalore. (Community Mental Health, Social Sciences, Research).
Mr. Darshan Shankar, Director, Foundation for Revitalization of Local Health Traditions,
Bangalore. (Folk Medicine, Indian Systems of Medicine).
Dr. Pankaj Mehta, Professor & Head, Department of Community Medicine and Vice Dean,
Manipal Hospital, Bangalore. (Community Medicine, Public Health).
HcaKh PolKysRcvicw of Draft NHP-99 doc
Page 14 of 14
I HEALTH POLICY
Ills of a draft policy
Draft National Health Policy mentions the ills that characterise the country's public health care system
but fails to provide satisfactory solutions.
T.K. RAJALAKSHMI
“The current annualper capita public
health expenditure in the country is no
more than Rs. 160. "
from Draft National Health
Policy-2001.
f | ’HE Draft National Health Policy,
L which was released in August, has
come under fire from several quarters.
The first salvo came from
f
the Jana
Swasthya Abhiyan (JSA), an organisation
dealing with public health issues. It has>
been close to 18 years since the last health
policy was framed in 1983. Therefore the
decision of the Union Ministry for
Health and Family Welfare to frame a
health policy document went largely
unopposed though there were complaints
of lack of consultation prior to the drafting stage.
Overall the draft policy, while emphasising federal principles and decentralisation in terms of public health and the role
of State governments, is silent on how to
remedy the ills of the public health care
system. The blueprint for the system lacks
the kind of vision that would ensure that
marginalised populations have access to
Ith care in the future. An assessment
.he public health infrastructure has to
be more than just platitudes and should
take forward the objective ofmaking equi
table health for all a reality. The draft pol
icy acknowledges some of the possible ills
in the health care system. However, it fails
in its basic function of including the fis
cally starved State governments as well as
people working in the area of communi
ty health in the task of addressing issues
of public health.
The Ministry put the draft proposal
on its Website and invited comments
from the various forums concerned with
health-related issues. The JSA, an
umbrella organisation of 18 national net
works dealing with community health
and people’s science, responded with a
comprehensive critique of the draft poli
cy. While welcoming the government’s
initiative, the JSA has drafted an alternaFRONTLINE, DECEMBER 21, 2001
tive policy document which incorporates
some valuable suggestions but excludes
aspects that, in the JSA’s opinion, mis
represent the situation. Members of the
JSA met recently to review the policy document within the framework of the peo
ple’s health charter evolved at a “national
people’s health assembly” held in Kolkata
in December 2000. The health assembly
was essentially a reiteration of the com
mitment of “Health for all - Now”. The
people’s health charter included, among
other things, a ‘basic needs’ approach and
the
the need
need to
to confront
confront the
the commercialisacommercialisation ofmedical education and health care,
issues that the people’s health assembly
expected the national health policy to
address.
While the draft makes several candid
admissions - for instance, it acknowledges the high levels of morbidity and
mortality and the poor functioning and
severe underfunding of health services it is silent about a strategy to make comprehensive healthi care available to all. It
expresses concern about the impact of
Trade-Related aspects of Intellectual
Property Rights (TRIPS) and globalisation policies on health and recommends
a higher level of expenditure on primary
health care; however, it lacks a comprehensive analysis of why National Health
Policy-1983 failed. One of the primary
premises ofthe 1983 policy was that India
is committed to attaining the goal of
“Health for All by the Year 2000 A.D.”
through the universal provision of com
prehensive primary health care services.
The words ‘comprehensive’ and ‘universal’are missing in the Draft Health Policy
of 2001.
The historic Alma Ata declaration, in
which many governments have committed themselves to a “Health for All” strategy, is not even mentioned in the 2001
document. Government representatives
from over 100 countries attended the
World Health Assemblyr at Alma Ata,
Kazakhstan, in 1978 and committed
themselves to making comprehensive
health care available to everybody, highlighted primary health care as a priority
area, and acknowledged that in the mat
ter of health care there were certain socio
economic determinants too that had to
be dealt with. It was for the first time that
health was not treated as a biomedical
issue, said Amit Sen Gupta of the All
India People’s Science Network, one of
the groups in the JSA. The 1983 policy
had initiated a phased, time-bound pro
gramme to set up a well-dispersed net
work of comprehensive primary health
care services, among other things.
Another area where the Union government has been criticised is its inability to involve the State governments in the
drafting of the document. Even the
Central Council of Health and Family
Welfare, an apex body of representatives
from all State Health Departments, was
not consulted. Also, the one month that
was~given to elicit comments and suggeswas
tions on the draft was deemed inadequate, especially in view of the fact that
the draft policy remained in the drafting
stage for three years. Public and community health organisations like the JSA
believe that the government acted in a
hurry to secure approval for the draft,
even without going through a consultative process with the State governments,
A I -<HE policy document brings to light
JL several unpalatable features, such as
the unacceptably high morbidity and
mortality levels, the resurgence of malaria, especially of the deadly P-Falciparum
type, and the dominant presence of
tuberculosis and the growing of drug
resistance in the types of infection prevalent in the country. In addition, waterborne diseases such as gastroenteritis,
cholera and some forms of Hepatitis continue to contribute to the high levels of
morbidity among the population. While
the concern and facts are genuine enough,
the remedies seem lopsided. For one, it
blames the failure ofthe public health systern for the unsatisfactory health indices.
The draft policy admits that the investment in public health over the years has
been comparatively low and has declined
as a percentage of Gross Domestic
79
Product to 0.9 per cent in 1999. The link- than 20 per cent of the population seek The policy’s prescription to raise the cur
ages between policy and ground realities ing
i out-patient department services and rent health expenditure from 0.9 per cent
than 45 per cent availing itself of of GDP to 2 per cent in 2010 fell drastiare missing. The Central budgetary allo- less
1
cation as a percentage ofthe total Central ttreatment as in-patients in public hospi- cally short of the health movement s
'ie demand that the expenditure should be
Budget over a 10-year period has been tals. The draft policy, while outlining th<
stagnant at 1.3 per cent while in the States poor infrastructure facilities in }public nothing less than 5 per cent of GDP.
The JSA has objected to what it calls
it declined from 7 to 5.5 per cent. Given hospitals, including the shortage of med“
prescriptions
for further privatisation”
ical
and
paramedical
personnel,
glosses
these figures, the current annual per capitalhealth
” expenditure
4
'•
works out to a pal- over the relentless pursuit of“family plan- of an already
t highly privatised health care
ning and immunisation” goals by the system. The proposal in the draft policy
try Rs. 160.
The need for the universalisation of PHCs. This aspect is mentioned in the to levy “user fees” at public hospitals, so
that those who can afford to should be
public health services has been substitut alternative draft.
’/ serve to drive
The draft policy suggests the need for made to pay, would only
ed by a new concern - decentralisation of
public health services. The intent, as is evi- specialists in “public health” and “family out the poorer sections. The government
medicine” and agrees wants to shift the burden on the sec
dent in the sub-section
The
draft
policy
that the current curricu ondary and tertiary sectors while
“Delivery of national
’ *i care
la
for graduate/post- strengthening the primary health
public
health
pro
is silent on the
medical sector by increased resource allocation.
graduate
grammes” in the draft
issue of private
The cursory mention of mental
degrees are outdated
policy, is a decentralised
medical colleges
and unrelated to con- health given the tragic events at Erwadi
public health machinery.
temporary community in Tamil Nadu involving the death of
The obsession with ver
and the need to
needs. “(Contemporary mental patients {Frontline, August 31,
tically structured pro
regulate them.
needs” should be spelt 2001), the casual treatment of women’s
grammes is evident in the
out, given the ambigui- health and the total absence of any menSimilarly, on the
draft, which states cate
ty ofthe phrase. TheJSA tion of children’s health have surprised
gorically that the role of
question of
draft contends that the activists in the health movement. The
the Central government
medical research, long-standing objective socio-cultural and economic factors that
in designing broad
it focusses more
of the health movement determine access to health care, particu
based public health ini
has been to limit spe larly by women, are glossed over in the
tiatives will continue
attention on
cialisation and re-orient draft policy. The JSA’s draft, however,
especially as the Central
frontier areas
undergraduate educa- contends that women’s health issues go
government will be
•sponsible
for
funding
of
research,
calling
tion
to equip doctc:ors to way beyond problems related to “child
reT
address
the health needs bearing” and the “reproductive tract” and
additional public health
them the thrust
of the common people, that the entire gamut of problems faced
services over a period of
areas.
However, by suggesting in a patriarchal society has to be considtime. Interestingly, the
the introduction of ered. Given the fact that more than half
policy arrogates to the
another course in fami the children under five in India are mal
Central government the
areas of technical and managerial exper- ly medicine and even specialisation in nourished, it is surprising that questions
tise for designing large-span public health public health, the draft policy inadver of their nutrition and subsequent well
programmes. The JSA has been especial- tently encourages the craze for specialisa- being do not find even a fleeting mention
in the draft. On the other hand, the pol
ly critical of this overwhelming role of the tion.
The draft policy is silent on the issue icy draft does re-emphasise the conr
government as it believes that designing
programmes should be the primary of private medical colleges and the need tion between population stabilisa.
to regulate them. Similarly, on the ques- and improved health indices. It states:
responsibility of the State governments.
The Centre, if anything, should play tion of medical research, it focusses> more “The synchronised implementation of
a coordinating role and provide technical attention on frontier areas of research, these two policies-National Population
and National Health Policy
and financial support wherever necessary. callingo them the thrust areas. This, the Policy-2000
,
The JSA, in its alternative draft policy, a JSA draft observes, does not take into - 2001 - will be the very cornerstone of
copy of which has been submitted to account
accountthe
the need
needtoto initiate
initiateand
andsustain
sustain any national structural plan to improve
Union Minister for Health and Family research
researchininpublic
publichealth.
health.There
Thereisisalso
alsono
no the health standards in the country.”
Welfare C.P. Thakur, suggests that in the mention of the need to regulate medical
What is required is a paradigm shift,
long run it is a more sustainable option to research
a shift away from the apparent panaceas
researchand
anddevelop
developethical
ethicalcriteria.
criteria.
integrate disease control strategies within
The effect of TRIPS is discussed in of population stabilisation and private
the decentralised primary health care net- the
the context
context of
ofaa possible
possible impact
impact on
on drug
drug sector participation in the health sector,
work, which should be linked to adequate prices but there is no mention ofany such But the language continues to be the
secondary and tertiary support services.
impact on medical research. While same. It is couched in platitudes with litOn the section dealing with the pub- lamenting that investment in public tie or minimal emphasis on rejuvenating,
lie health infrastructure, JSA draft sug- health has been comparatively low, the strengthening and making effective the
primaryhealth
healthcare
caresector.
sector.This,
This,accordaccordgests that die primary health centres draft policy fails even to record that such primary
(PHCs) have been reduced to centres for investment as a percentage of health ing to the draft policy, is closely linked
family planning aid and immunisation. expenditure was perhaps the lowest in the with the quality of public health services,
It is this situation, coujipled with inade- world and that the country has the which is in turn reflected in improved
quate facilities, that has resulted in less world’s most privatised health system, public health indices. I
80
FRONTLINE, DECEMBER 21, 2001
Page 1 of2
Community Heaith Ceil
From:
To:
Sent:
Subject:
"jo" <ivarghese@cmai org>
<pha-ncc@yahoogroups. com>
Tuesday, March 23, 2004 1:25 AM
[pha-ncc] Congress Manifesto and health
Dear All,
The congress manifesto speaks on health in just few words. Details are available in this
link ://www.itindustries.com/congress/manifesto-2004.htm
Joe
CMA!
" The congress will raise public spending on health to at least 2 -3% of
GDP with the focus on primary health care over the next five years and
5% of GDP over the next decade, the welfare of the Disabled in respects
will receive urgent attention.
Some state governments administered by the congress have introduced
innovative health insurance programmes. A national scheme health
insurance for families living below the poverty line will be proposed.
7
The congress will introduce a new community anchored health worker
scheme and implement it with the involvement of people’s organisations
and panchayat raj Institutions.”
X-
1^1
Yahoo! Groups Sponsor
ADVERTISEMENT
I
' i_ 1
! —J
*A^rv-
!
i
Yahoo• Groups Links
3/26/04
Page 1 of 1
-3
H
i
THE KARNATAKA STATE
INTEGRA TED HEALTH EOI.ICY
■r.
Based on the Report of the Task Force on Health & Family Welfare, April 2001 and
amended as per the Proceedings of the Workshop organized by the Directorate of Health and
Family Welfare Services, Government of Karnataka on October 4, 2001, at the Urban
Health Research and Training Institute, Bangalore and subsequent meetings held under the
Chairmanship of the Principal Secretary, H & .F W Dept, on 20:9:2002 , 13:12:2002 and
9:1:2003. .
f
Depiirlinent of lleaKii
Hiniily WeH'iHv
Governmeul of KornoLiko
I: i H ■
i.H.i
'
i;
t i i •. c 11 s •, i ,; < ; i ’ 1! i i
n;.j; i
t>tHiiii' {i •
. iH'hl li!} ! ! :
•L
" p-<<l AOZ-l - -'f
C.
,A'
liNcgr.ucd llc.ilili Policy Draft doc
O
h '■1
. i
t
THE KARNATAKA STATE. INTEGRATED HEALTH POLICY
Rationale for a State Health Policy
I
Introduction..................................................................................
1.1 Health gains
1.2 Health Gaps.....................................................................
2.
3.
4. 5.
Karnataka: Vision for Better Health and Health Care..,
Karnataka:Mission Statement on Health and Health C::ire
Karnataka Health Policy Perspectives and Gouls............
Karnataka Health Policy Components
5.1. Scope of policy-comprehensiveness and integration
5.2. Public health approach and primary health care
Strategics9
5.3. Equity in health and health care
5.4. Quality of care
5.5. Multisectorality and intersectoral coordination
5.6. Private, public and voluntary sector partnerships
5.6.1 Autonomous Medical Institution
5.7. Health financing
5.8. Health planning
5.9. Health management and administration
5.10. Environmental health
5.11. Nutrition
5.12. Population stabilization
5.13. Education for health personnel
5.14. Rational drug policy
...............................................
5.15. Medical industry (diagnostics, bio-medical equipment.
health accessories)
5.16. Medical and health research
5.17. Indian systems of medicine and homeopathy
5.18. Health promotion ...
6
<
Policy Components on Priority Ilrnldi Problems mid Issues
6.1. Communicable / infectious diseases
6.2. Women’s, health
....................................
6.3. Children’s health
6.4. Mental health
6.5. Prevention and control of non-communicable diseases
6.6. Disability
6.7: Occupational health and safety
6.8. Dental liealth/oral health
6.9. Emergency health services and trauma care
( ross-cutling Policy Issues
7. J Medical and public health ethics
-Process and iinplemciUaiio11 1 acl<.>i s
( 'onclusions.................................... . .........................
liUcgrjicd Health Policy_ Draft doc
Rationale for a State Health Policy
The State has so far followed policy guidelines through the framework of successive Five Year
Plans developed by the Planning Commission, decisions of the Central Council of Health and
Family Welfare, central health legislation and national health programmes developed by the
Central Government. Over a period of time, separate policies at the National level have been
developed for Health (1983), which was revised in 2002, Education for Health Sciences (1989),
Nutrition (1993), Drug Policy (1986 and 1994), Pharmaceutical Policy 2002, Medical Council of
India (MCI) guidelines (1998, 1999 and 2000), Blood Banking (1997), the elderly (1998), and
Population (2000), among others. All these have served the State well in developing its health
system, and will continue to be used as guidelines for further growth.
A National Health Policy - 2002 has been announced and provides a framework within which the
Health Policy of the State would refashion the elements therein to meet the current needs of the
State. The State Health Policy would be based on the specific needs of the State and recognise
' -regional disparities.
Health however is constitutionally a State subject. Health needs, defined socio-epidemiologically,
■y between States and even districts, requiring more specific planning. Health expenditure is
...et largely by the State budget, with 82% of public sector expenditure on health from the State
Government of Karnataka and 18% from Central Government. A comprehensive Karnataka State
policy for the integrated development and functioning of the health sector is therefore being
articulated explicitly, for the first time. The policy, with a strong emphasis on process and
implementation, will be an instrument for optimal, people oriented development of health
services.
The State Health Policy would be based on the following premises -
*
*
*
*
*
It will build on the existing institutional capacities of the public, voluntary and private health
sectors.
It will pay particular attention to filling up gaps and will move towards greater equity in health
and health care, within a reasonable time frame.
It will use a public health approach, focusing on determinants of health such as food and
nutrition, safe water, sanitation, housing and education.
It will expand beyond a focus on curative care and further strengthen the primary health care
strategy.
It will encourage the development of Indian and other systems of medicines.
It views health as a reasonable expectation of every citizen and will work within a framework
of social justice.
More importantly it is intended to be a guiding document that needs to evolve and be changed in
ttsponse to changing situations.
Inlcgr.ilcd llcallh Policy^ Draft doc
I
]
1.
In trod action
1.1
Health gains
Dunng the past century and particularly after independence in 1947, several gains have been made
in health and health care in Karnataka. Life expectancy at birth has increased from 37.15 to 61 7
years and from 36.15 to 65.4 years for males and females respectively, between 1951 and 2001
The infant Mortahty Rate (IMR) declined from as high as 148 /1000 live births in 1951 to 69 in
1981 ’
t0 57 in 2000 (SRS 200()y In this sensitive key indicator, the goal of 60 fixed
dOS/lOOO8 NfItOnal.H^'tl11 Po’icy has been reached- The Crude Birth Rate has fallen from
to 2 132n 1Z oTs 'n!
2? ° m 2T 3nd thC tOtai fertiHty rate from 6 0 chiId™ in 1951
to 2.13 m 1998-99. Small pox has been eradicated. The State has become free of plague and more
recently of guinea worm infection.
The incidence of polio cases has been reduced to zero by
December 2000 and until now, for more than two years, the ‘nil’ status has been maintained The
P™®reSS in bnn8ing down Crude Death Rate by more than two thirds from 25.1 in 1951 to 7 8 in
2000 is noteworthy. Public health care programmes riclily deserve much of the credit for this A
brief picture of the gains is depicted below.
________ HEATH INDICATOR
Life expectancy at birth (years)
Males
______ Females
Crude Birth Rate (per 1000 population)Crude Death Rate (per 1000 population)
IMR (per 1000 lbs)________ _________
Malaria (API)
_______
Leprosy (cases/10000 population)
1951
1971
1981
1991
2001
37.15
36.15
40.8
. 25.1
148
.NA
NA
50.9
50.2
37.1
55.4
55.7
28.3
ILL
9.1
110
58.1
58.6
26.9
9.0
80
1.16
16
61.7
65.4
22.0*
7.8*
57*
3.93
2.45
120
1.35
NA
±22.
31
* - Sample Registration System 2000
thTfohovvZtablT1115 ,n the 11631111 infiaStrUCtUre 0Ver the years in Karnataka are apparent from
HEATH INFRASTRUCTURE
No. of Sub Centers________
No. of Primary Health Centers ~~
No. of Primary Health Units
Hospitals_______
Beds
~
Doctors
StafFNurse
1970-71
NA
265
917
114
NA
NA
NA
1980-81
3334
300
1215
137
24597
NA
NA
1990-91
7793
1198
626
176
31432
4370
4607
2000-01
8143
1676
583
176
43112
5202
5317 '
NA: - Not Available
tmegraied Health Policy^ Draft doc
2
favourably with the national
The health and demographic scenario in Karnataka, compares
average as could be evidenced from the following table.
OEM OGR A PH IC IND I GA' FORS
SI
No
1
2
3
4
Indicator
Crude
Birth Rate
Crude
Death Rate
Natural
Growth Rate
Infant
Mortality Rate
NOTE
1;2
1951
K
I
1971
K
1991
1997
2000
I
K
I
K
I
K
I
40.8 39.9 37.1
41.2
26.9
32.5
22.7
27.2
22.0
25.8
25.1 27.4 17.0
19.0
9.0
11.4
7.6
8.9
7.8
8.5
15.7 12.5 20.1
22.2
17.9
21.1
15.1
18.3
14.2
17.3
NA
129
77
80
53
71
57
68
148
K - Karnataka
120
I - India
NA - Not Available
Health gaps
However, gaps remain. Large rural - urban differences remain, exemplified by IMR estimates of
70 for rural areas and 25 fot urban areas (SRS, 1998). Despite overall improvements in health
indicators, inter- district and regional disparities continue. The five districts of Gulbarga Division
(Bidar, Koppal, Gulbarga, Raichur, Bellary), with Bijapur and Bagalkot districts of Belgaum
division continue to lag behind. Under -nutrition in under-five children and anemia in women
continue to remain unacceptably high. Women’s health, mental health and disability care are still
relatively neglected. Certain preventable health problems remain more prevalent in geographical
regions or among particular population groups. Structural reforms, as suggested by the Task Force
on Health, have to be made and more effective management practices imbued with accountability
have to be introduced to ensure swift and effective local responses to health problems.
The relatively low level of public confidence in public sector health services, particularly at
primary health centres, is recognised. Lack of credibility of services adversely affects the
functioning of all programmes.
Underlying reasons for implementation gaps need to be
understood and addressed.
2. Karnataka Vision Statement for better health and health care:
2.1
Karnataka State recognizes the immeasurable value of enhancing the health and well being
. of its people. The State’s developmental efforts in the social, economic, cultural and political
spheres- have, as their overarching goals, improved well being and standards of living, better
health, reduced suffering and ill health, and increased productivity of its citizens. It is recognized
that health and education arc central to development. Health is an individual and collective
responsibility. The constitutional mandate, role and responsibility of the State in providing
(nlcgratcd Health Policy_ Drab doc
including mlintemnTe of staXdsTfZd
heahh
1
provision
and related endeavours
development objectives.
of health care, is of critical i
■ importance m meeting these social
d""'1’ OreM'“tiM (WHO 1948) as
rfnntty”, creali„8 lhe abiB|y ,o kXX X ± 18
l,0,
'he •Xue of diX ’
1- .s the .deal towards which tadlvidutds and .XutioTXX XXX'
'978)-
s.h
Howof the sever.! achieve
-e Proud
„lade In
proved
mel, cuorem cooce™ md conrnitmenis telX"’ rc“e”,zh«’ that some goals have yet to be
*
*
11 recognizes tire need to ensure that ,
and are always accessible to the citizens.good quality health care services are
evenly distributed
V
*
If is aware of the c_Jaiu
pharniaceutical products that
their impact.
of diagnostics, medical
*
*
=mpiom„t, “:r‘sx xlXdXr;,x«LXtoXrs afci
^«X2XXX=eiX"h b* *.. . - poXXXX;0™8 re“8"itta- ">«
It
access to comprehensive health
*
*
■
care has a
Jf ako 1 ecognizes the urgent need to address
nderpm them, as poverty and ill-health linkages
are strong,
poverty
and inequality, and the social forces that
coordination to tciclcruTimp
°Cial <develo
Pnient Policies
pursuing Ssocial
’
and mcreasing inter-sectoral
— Wrovcment
manner.
1J11PI0Vement of health of711
all sectors of
society in an equitable
/r: g
■
tl
.....
■rtcsnicd Health p0|icv_ Drnft
4
0
si ■
I
*
It recognizes the critical role of the state to initiate and steer policies;
- to ensure equity and quality of health care;
to promote the sustainable development of public health services;
to promote community / peoples’ participation in the governance of health
services;
to facilitate private and voluntary health sector growth as augmenting health
care while maintaining professional and etliical standards and keeping in mind
distributive justice;
to provide required resources to dilferent levels of health care , to improve
accountability and transparency in the Health Sector.
3.
Mission Statement on Health and Health Care
The mission of the Department is to provide Quality Health Care with Equity.
The State will provide improved access to good quality health care and promote an enabling
environment for development of the health sector. It will endeavour to provide quality health care
with equity, which is responsive to the needs of the people, and is guided by principles of
transparency, accountability and community participation.
4.
Karnataka health policy perspective and goals
1.
2.
3.
4.
5.
6.
7.
8.
9.
4
To provide integrated and comprehensive primary health care.
To establish a credible and sustainable referral system.
To establish equity in delivery of quality health care.
To encourage greater public private partnership in provision of quality health
care in order to better serve the underserved areas.
To.address emerging issues in public health.
To strengthen health infrastructure.
To develop health human resources.
To improve the access to safe and quality drugs at affordable prices.
To increase access to systems of alternative medicine.
Indicators and systems for monitoring and evaluation that would allow review and assessing of
progress towards achieving specific objectives that derive from the goals would be formulated and
put in place.
5.
Karnataka Health Policy Components
. 5.1
Scope of policy - coniprehcnsivcncss and integration
To facilitate the balanced development of health systems and services responsive to health needs
and aspirations of people, Karnataka State considers it necessary to have a comprehensive health
I
I
I
*■
tiucgraicd Health Policy, Draft doc
5
-
''■I
policy statement in which different elements are integrated together and viewed as a whole.
Various units and sub-sectors may evolve more detailed policy guidelines. However, this
comprehensive statement will allow each one to be placed in the context of others’. A
comprehensive approach is important, since at the point of delivery of services or the point of
contact between the public, the patient and the provider, there is need for horizontal integration.
The State will undertake measures to operationalise a comprehensive, integrated health service,
with promotive, preventive, curative and rehabilitative health care services at primary, secondary
and tertiary levels, linked together with good referral systems.
The Health Policy would be consistent with the separate policies that may be formulated for
related social sectors and, along with the latter would constitute the charter for social development
of the people of the State.
5.2
Public health approach and primary health care strategies
The state recognizes the value of practicing public health and primary health care, for the common
good of all citizens. It has committed itself to revitalizing these aspects. While the clinical or
curative approach to health is focused on individual persons and their disease problems, public
health tries to protect, promote, restore and improve the health of all people, through collective
action. Programmes, services and institutions give priority attention to disease prevention and
health promotion, responding to the health needs of the population as a whole, particularly the
deprived. Public health addresses the basic determinants of health. Public health interventions
address coinmunicable disease transmission and attempt to reduce risk factors for other diseases.
An evidence-based approach using action research and other methods would be adopted to
develop and fine tune strategies. This will be supplemented by feedback from the public, from
patients and from frontline implementers or health personnel. This will enable the development of
a problem solving approach that is area specific.
Public health and primary health care work in synergy, particularly emphasizing principles of:
•
•
•
•
Inter-sectoral coordination at all levels, especially at the district and below;
Community participation through Panchayati Raj institutions and other mechanisms and
fora for involvement in decisions making concerning their own health care;
Equitable distribution of good quality care; and
Use of appropriate technology for health.
The primary health care strategy does not focus only on the primary level of care but also on
the secondary and tertiary levels.
Public health recognizes and attempts to address the socio-cultural, socio-economic and
demographic factors that affect health status and implementation of health programmes.
Im
1 he Karnataka State Integrated Health Policy would attempt to ensure adequate availability of
personnel with specialization in public health to discharge the public health responsibilities in the
State.
biicgniied Health Pohc)_ Draft doc
6
I
k.d
I
Towards this endeavour the State would take up measures: ■1)
2)
3)
4)
5)
5.3
To take up two months foundation course for newly recruited Doctors in Primary
Health Care, Administrative, Financial matters.
Upgrade the State Institute of Health & Family Welfare and start Diploma course in
Public Health for doctors and Public Health Nursing courses for Staff Nurses.
Start Diploma and Certificate Course in Health Management and Hospital
Management through Indira Gandhi National Open University.
To include Health / sickness topics in primary, middle and higher-level general
education to the extent possible.
To enhance quality care, “Quality Indicators” for primary, secondary and tertiary
Health care will be standardized and continuously monitored at various levels of
Health and Medical care institutions.
Equity in health and health care
i;
Equity will be a key policy thrust, encompassing four main parameters, namely; region,
disadvantaged groups (Scheduled Castes and Tribes), gender and vulnerable groups (street
children, elderly).
!
a) Region
The State is deeply
C
concerned by recent data analyses that reveal unabating regional
disparities in health status,, in distribution of Primary Health care facilities and their
utilization.
The regional disparities are apparent in the Composite health infrastructure index, based
on: the (a) doctor: population and (b) Government hospital beds: population ratios and (c)
drinking water facility of 40 or more Litres Per Capita Per Day (LPCD) as shown in the
table overleaf Out of the 56 relatively developed talukas in the state, only 15 (27%) are in
the Northern Karnataka region and the remaining 41 (73%) in the southern. Among the 39
most backward taluks, as high as 33 (85%) belong to the Northern Karnataka.
i
■
3
Integrated I leaJlh Policy_ Draft doc
7
I
i
Ip
i
COMPOSITE HEALTH INFRASTRUCTURE
Relatively Developed
Taluks
Percent
age
Percent
share in
age
the
total
SI.
Division /
share in
Relativ
No
Region
the total
No
ely
taluks of
Develop
the
ed
Division
Taluks
/ Region
of the
State
2
J.
3
4
5
2 ! Bangalore 13 25.49
23.21
2
Mysore
28
63.64
50.00
~ 41
I
SKR
43.16
73.21
Belgaum
13
26.53
23.21
5_ I Gulbarga
02
6.45
3.58
2 I NKR~ In 18.75
26.79
Karnataka | 56
32.00
100.00
J
No,c
Backward Taluks
No
6
17
07
24
13
03
16
40
More Backward Taluks
Most Backward Taluks
Percent
age
share
in the
total
More
back
Ward
Taluks
of the
State
11
40.00
20.00
60.00
22.50
17.50
40.00
100.00
Percen
tage
share
in the
total
Most
back
ward
Taluks
of the
State
14
12.82
2.56
15.38
35.90
48.72
84.62
100.00
Percent
age
share in
the total
taluks
of the
Division
I Region
Percentage
share in the
total
backward
Taluks of
the State
No
Percent
age
share in
the total
taluks of
the
Division
/ Region
7
33.33
15.91
25.26
26.53
9.68
20.00
22.86
8
42.50
17.50
60.00
32.50
07.50
40.00
100.00
9
16
08
24
09
07
16
40
10
31.37
18.18
25.26
18.37
22.58
20.00
22.86
skr ■
>kR ■ KoppBel8a“m’BiiaPUI’ Ba8a":Ot' Dtanrad-
i
8
.
...
No
Percen
tage
share in
the total
taluks of
the
Division
/ Region
12
05
01
06
14
19
33
39
13
9.81
2.27
6.32
28.57
61.29
41.25
22.28
Total Taluks
No
Percen
tage
15
16
51
100.00
44
100.00
95
100.00
49
100.00
31
100.00
80
100.00
175
100.00
Kod.8U,
“a. Gulbarga, Bidar, Raichur,
I
i
INDEX
Information on the disparities in health status by social and economic background
characteristics like religion, caste and standard of living can be indirectly inferred from the
important indicator of child mortality and could be used as a yardstick for all practical
purposes.
I
i
The following statement throws considerable light on the dillcrcnces in the levels of infant
and cliild mortality by these significant background characteristics, in Karnataka.
I
Background characteristics
I
I
i'
f-
Residence
Urban
Rural______________________
Mother’s Education
Illiterate
Literate<middle school complete
Middle school complete
High school complete & above
Religion
Hindu
Muslim_____________
Caste/Tribe
Scheduled caste
Scheduled tribe
Other backward class
Other_______________
Standai d of living index
Low.
Medium
High_______________
Total
Infant
Mortality
Child
Mortality
Under-Five
Mortality
44.1
70.3
12.1
27.1
55.7
95.5
76.2
29.2
17.6
103.1
58.8
55.8
43.1
41.9
51.7
37.8
4.3
5.6
$
65.5
49.5
24.0
17.0
88.0
65.6
69.9
60.6
37.4
38.9
18.7
56.4
14.2
104.6
120.6
78.2
69.8
82.2
54.6
38.2
62.3
38.5
13.6
12.4
22.4
117.5
67.5
50.1
83.3
85.0
I
Source: - National Family Health Survey - 11 (1998 - 99)
I
Integrated Health Policy_ Drafi doc
9
Ifl
1I
1'K
■f.1
"4
Further proof of imbalances / differences in the health indicators is available from the district wise
indicators reflected in the following statement.
DISTRICT WISE SELECTED KEY INDICATORS OF KARNATAKA
SL.
No
District
I
1
HASSAN
59.32
15.20
75.10
19.70
69.70
92.80
81.55
2
SHIMOGA
67.24
16.50
69.30
22.80
83.00
92.90
80.37
3
KODAGU
72.53
22.00
70.60
18.80
79.40
94.80
80.06
4
77.39
68.48
4.50
63.70
32.00
91.50
86.00
5
□.KANNADA
U.KANNADA
15.00
66.00
27.20
86.10
89.90
78.77
76.1
6
UDUPI
74.02
4.50
63.70
32.00
91.50|
86.00
75.97
II
y
Girls
Current Birth
Complete
Female Married users order 3 Safe
Composi
Immunizati
Literacy below 18 of FP
&
Deliver
te Index
on
%
years Method above
y %
%
%
%
%
%
GOOD PERFORMING DISTRICTS *
AVERAGE PERFORMING DISTRICTS *
.7
MANDYA
51.62
37.00
71.70
26.10
61.90
88.00
75.86
8
MYSORE
55.81
47.90
65.40
23.90
69.70
92.70
75.70
9
BANGALORE (R)
78.98
21.05
63.00
16.40
79.10
83.70
75.34
10 BANGALORE (U)
78.98
37.00
60.10
26.10
90.60
77.00
75.19
11 CHITRADURGA
12 TIJMKUR
13 DHARWAD
14 CHAMARAJ NAGAR
54.62
30.05
59.90
34.40
53.80
88.40
73.98
57.18
43.02
61.30
61.20
65.40
27.30
37.40
23.90
63.50
65.30
69.70
88.00
74.80
92.70
73.97
73.03
72.18
15 CHIKMAGALORE
64.47
27.10
36.50
47.90
37.00
71.40
26.10
78.00
83.50
72.13
16 KOLAR
17 GADAG
52.81
33.50
57.10
29.70
59.20
90.60
71.92
52.58
36.50
61.20
37.40
65.30
74.80
69.72
18 BELGAUM
52.53
55.80
61.80
36.70
68.60
64.80
68.75
19 HAVERI
57.60
36.50
61.20
37.40
65.30
74.80
65.66
III
62.20
POOR PERFORMING DISTRICTS
20 BELLARY
46.16
44.20
50.40
48.60
54.00
52.60
65.54
21
58.45
35.50
59.90
34.40
53.80
88.40
65.43
DAVANAGER.E
Imcgratcd Health Policy_ Dnirt cloc
10
SL.
No
District
Girls Current Birth
Complete
Female Married users order 3 Safe
Immunizati Composi
Literacy below 18 of FP
&
Deliver
te Index
on
%
years Method above
y%
%
%
22 BIJAPUR
23 BIDAR
24 RAICHUR
25 GULBARGA
26 BAGALKOT
27 [KOPPAL
%
%
%
POOR PERFORMING DISTRICTS
46.19
64.80
47.10
43,00
50.10
50.01
67.60
50.60
52.90
52.50
50.30
62.86
~60~55
36.84
57.10
45.40
52.80
48.00
37.20
58.34
38.40
47.70
39.20
53.70
47.70
25.30
58.31
44.10
64.80
47.10
43.00
50.10
53.20
54.71
40.76
57.10
45.40
52.80
48.00
37.20
53.09
53.20
Source: National Commission on Population, GOI, 2001
Note: - * - The classification is based on the composite index.
The regional and inter-district disparities would be factored into the mechanisms of
allocation of resources among the regions and districts
b) Disadvantaged groups
The Scheduled Castes and Scheduled Tribes will receive priority attention. Besides primary
care, access to complete treatment, follow up and referrals, to secondary and tertiary care
services at subsidized costs, will be assured. For indigenous people, a package commensurate
to their needs will be developed and implemented.
c) Gender
i
The poor status of women's health, the declining gender ratio and poor coverage and quality of
mother and child health services are areas of concern. Measures to improve women's health
status and access to care will be implemented and closely monitored. Efforts will be made to
inciease the number of women doctors, senior and junior health assistants, male / female
(Lady Health Visitors and Auxiliary Nursing & Midwifery) by providing adequate reservation
or women in the health educational institutions and appointments and providing better
residential facilities and personal security. Quality of maternal and child health services will
be improved, particularly in emergency obstetric care. Widely prevalent conditions affecting
women, such as anemia, low backache, cancer of the cervix, uterine prolapse and osteoporosis
will be addressed. Services for psychosocial problems and emotional distress will be
developed. Empowerment of women for management and monitoring of health services will
be encouraged and supported. Programmes for the special needs of adolescent girls and boys
will be developed in collaboration with the Department of Education. Enforcement of
Prenatal Diagnostic Techniques (Regulation and Prevention of Misuse) Act will be
strengthened and promotional measures taken to correct the declining gender ratio.
bucgrnlcd HeaJlh Policy_ Draft doc
11
<!lY<LhLmiN^g.nHij)s
Innovative, flexible and collaborative approaches would be adopted for meeting the health
needs of street children, out of school and working children, persons with disability and other
vulnerable groups in the community.
c) Elderly :
With the increasing life expectancy, the proportion of senior citizens, that is, those of age 60
years and above would continue to increase. Necessary allocation of resources would be
necessary for geriatric medicine and geriatric health care to improve the health status of the
elderly and to make them socio-economically productive and happy. The State will promote
research on geriatric issues and facilitate the establishment of appropriate geriatric health care
facilities.
5.4
Quality of care
Having developed an extensive Statewide health care infrastructure over the past five
decades, an important policy thrust area in the next phase will be improvement in the quality of
care and patient satisfaction. Quality care parameters and Standards of care would be developed
for the different levels of Health Care Institutions. Mechanisms will be established to assure good
quality medical and public health care in public institutions and to facilitate similar standards in
the private and voluntary sector. Mechanisms will include accreditation, repeat registration,
continuing education for health care personnel, patients charters and grievance redressal systems’
Wherever necessary, appropriate legislation to facilitate these measures would be considered.
Provision of good care would be the primary concern.
The possibility of the early enactment of the Karnataka Health Care Establishments Bill to
ensure acceptable standards of care would be considered as an important step in assuring quality
of care.
The Karnataka Health Systems Development Project has already taken initiatives for obtaining
ISO 9002/1994 Certifications for six District Hospitals by February 2003 - in three services viz.,
Maternity Services, Blood Bank Services and Equipment Maintenance. The same will be
extended to other services and in other District Hospitals in a phased manner. Standard Operating
Proceduies (SOPs) and Clinical Protocols and Guidelines will be laid down and adopted to ensure
appropriate patient care and the rational use of drugs. The Citizens Charter, the Mission statement
and the Quality Policy will be displayed in prominent places in the hospitals. Complaints /
Suggestion boxes will be made available to patients for redress of their grievances.
5.5
M ul (iscctoralil \ and iiili r -sectoral coordinal ion
Inter-sectoral coordination has been inadequate even though its importance was
recognized since the late 1970’s. Working links, joint programmes and regular communication
lidegnilcd Health Policy_ Draft doc
will be institutionalized between the Directorate of Health and Family Welfare and the
Departments of Women and Child Development, Education, Rural Development and Panchayati
Raj. and the Public Distribution System in particular. Links with the Watpr Supply and Sewerage
Boards, Pollution Control Boards will be developed with clarity regarding the roles of each
department and areas of shared responsibility. Functional Mechanisms at village/ward level
taluk, district and state will be developed.
Intra-sectoral linkages will be strengthened between the Directorates of Health and Family
Welfare, Medical Education, Indian Systems of Medicine and Homeopathy, the State Institute of
Health and Family Welfare, the Dings Directorate and the Rajiv Gandhi University of Health
Sciences.
5.6
Public, private and voluntary sector partnerships
The State Policy recognizes the role of the voluntary and private sectors in public health
care. Though already existing in an adhoc and often informal mariner, public, private and
voluntary partnerships will be further developed in a planned, systematic manner in order to
develop in spirit and practice for better health care and also for optimal utilization of health
resources. District and Taluk health action networks and issue-based networks will be encouraged
with active participation from the public sector in such voluntary sector initiatives. Participation
pf voluntary and private sector will be enhanced through outsourcing certain services, in
infrastructure maintenance and investments in health services.
5.6.1
i
Autonomous Medical Institutions
The important role of autonomous medical institutions is recognized. They encourage
professional autonomy and the adoption of modern medical technology and provide specialized
services of a high order. They would be encouraged to enhance their capacity to raise funds
through appropriate user charges and other means so that they are able to enhance both the scale
and quality pf the services they render. However, while doing so, the need to ensure that access to
such services are available to the economically disadvantaged would be kept in mind.
5.7
Health Financing
Greater attention will be paid to equitable health financing systems in view of the rising
costs of medical care and the large out of pocket payments that often have adverse consequences
on the poor. Social and health insurances schemes, prepayment schemes, selection of cost
effective strategies including use of generic drugs, central purchasing and better management of
infrastructure assets, equipments and transport, would be the mechanisms that would be instituted
for enhancing both coverage and quality of health care.
Fhe government spending on health will be brought up to acceptable norms, as investments
in the social sector are recognized to produce gains in human development. The optimum levels
of budgetary allocations for health care would be reached in a phased manner. Equitable
proportions of spending will be in the primary, secondary and tertiary levels (55%, 35% and 10%
suggested by National Health Plan - 2002, Government of India) and between rural and urban
Uucgnitcd Heal di Policy_ Draft doc
|
areas. The Government would seek to implement, to the extent possible, the recommendation
contained in the National Health Policy, 2002, to increase the State health allocation to 7% of the
total Budget by 2005 and 8% by 2010. Resource flows will help increase access to quality health
care in rural areas. Allocation and spending on health promotion will be enhanced in keeping with
recommendations of the Central Council of Health and Family Welfare.
A system for state health accounts, with necessary databases, will be developed to monitor
health revenue and expenditure, including those from externally assisted projects and centrally
sponsored schemes. Capacities for financial and administrative management will be strengthened.
Budgeting and administration of health services will be made more flexible lor timely
appropriate decision-making and effective utilization of allocated resources without
compromising transparency and accountability. Pilot studies will be undertaken and encouraged to
experiment with innovative health financing schemes such as community financing and social
insurance, with particular focus on the rural and urban poor. Health insurance will be promoted.
User charges for those segments of the society who can pay for the services will be levied. ‘Rogi
Kalyan Samithis’ will be formed at those hospitals which collect user charges for ensuring their
effective utilization and for mobilization of additional resources locally by promoting public
donation and contribution.
Private funding for the execution of health infrastructure creation and maintenance
projects will be tried and, if successful, would be replicated.
5.8 Health Planning
Health Planning will be undertaken in consonance with the National Health Policy and
Programme guidelines. The State will institutionalise such planning through the establishment of
the Planning and Monitoring Division in the Commissionerate of the Health and Family Welfare
Services. Since there is an acute shortage of Epidemiologists in the State, the Epidemiological
units will initially work at the State Level. Doctors will be encouraged to pursue Postgraduate
Epidemiological Courses & depending on the
“ availability of personnel such epidemiological units
will be extended to all the Districts as well. Tliis will facilitate the Planning and Monitoring
Division in getting qualitative data on Disease Surveillance through the Health Management
Information System.
Necessary expertise would be established in the Directorate of Health, including a Health
Economist, a Sociologist and consultant in information technology. The Population Centre, which
is currently active in health and population related research would also enhance the in-house
professional capacity of the Directorate. The State Institute for Health and Family Welfare and the
Rajiv Gandhi University of Health Sciences would also be involved in the planning of health care
services.
5. .V
llenllh Maiingeincnt and Administration
Skills in health management and administration will be strengthened through a process of
recruitment of trained personnel and in-service training. Two cadres in the health services are
envisaged, for medical care and for public health respectively. The formation of these two distinct
• cadres would, it is expected, enhance the quality and outreach of both the public health and
clinical services.
idle grated Health Policy_ Draft.doc
14
The Health Management Information System will be an important means for decision
making and for introducing correctives at institutional and higher levels.
Issues such as leadership, governance, strengthening institutional capacity, developing
efficient communication systems within and between tiers and levels, will receive priority
attention, with the help of experts and institutions such as the Indian Institute of Management.
Sections for engineering, construction and infrastructure maintenance; equipment procurement
and maintenance; drug procurement and transport procurement and maintenance, will be
strengthened in-house and developed further into specialized units. These are critical support
areas for the health system to function optimally.
The outsourcing of certain activities including contracting out non-clinical services such as
cleaning, laundry, security, dietary department etc., will be continued and extended.
• The mismatch of specialists in secondary care hospitals will be minimized
• Vacancies of technical staff will be filled up
• Health management and hospital administration training courses on a regular basis to all the
Health Programme Managers and Hospital Administrators will be taken up.
• The services of non-medical Management Specialists will be utilized to strengthen the District
Health System and also National Health Programmes.
•
The State Institute of Health and Family Welfare will be developed into a high quality centre for
training and continuing education, especially in the fields of public health, management of health
services and medical ethics, linked with the Rajiv Gandhi University of Health Sciences. It will
provide orientation and in-service training to personnel from the Department of Health. It will be
linked with the district and health worker training centres. Its infrastructure will be upgraded
especially, library, teaching halls with audiovisual equipment and computer facilities, as also
personnel. It would offer certificate and diploma courses. It will be encouraged to develop links
with other educational and specialized institutions, including the Indira Gandhi Open University.
It will also undertake research studies.
i
5.9 Environmental Health
Environmental health is an issue of great concern to the State. Unplanned industrialization,
inadequate monitoring and control, and excessive use of chemical pesticides, can and do have
serious health effects on people. Motor vehicle fumes also add to the toxic chemicals in the air.
The State will continue to undertake measures to control exposure to these sources of pollution in
order to protect its citizens from these health hazards.
i
The State will encourage establishment of common facilities for the treatment of
Biomedical waste not only in large cities but also in towns catering to a population of more than
five lakhs, through Public-Private partnerships, with the assistance of the Pollution Control Board.
The State will ensure water quality of the accepted norms and standards through a
• monitoring and surveillance system.
Health education and Health promotion activities will be undertaken to promote personal
hygienic practices as a safeguard against environmental health hazards.
Inicpaicd Health Policy_ Dnifl.doc
15
5.10
Nutrition
The magnitude of under nutrition and nutritional deficiencies in Karnataka revealed by recent
data, place nutrition as a major public health issue in the state.
The Health Policy reflects the National Nutrition Policy (NNP) adopted by the Govt, of India in
1993 and the National Plan of Action in Nutrition (NPAN) developed in 1995 by the national
Standing Committee on Nutrition.
The goals to be achieved by 2007 are:
(a) Reduction of under nutrition (Gomez classification) among pre-school children as follows severe under nutrition from 6.2% (1996) to 3%; moderate under nutrition from 45 4%
(1996) to 30%.
(b) Reduction in anemia among women from 42% (1998) to 30%.
(c) Reduction in anemia among children from 66% (1998) to 50%.
(d) Reduction in newborn with low birth weight from 35% (1994) to 10%.
(e) Elimination of blindness due to Vitamin A deficiency and elimination of iodine deficiency in
goiter prevalent districts.
(0 Promotion of balanced, low cost diets using locally available foods for different age groups
including children adolescents, pregnant and lactating mothers and the elderly.
(g) Improving household food security through poverty alleviation programme.
I
Short-term interventions would be formulated to set district wise goals and targets for appropriate
nutrition interventions for vulnerable groups, particularly:
a) Focusing on under-twos with supplementary foods. Also, expanding the nutrition intervention
net (Integrated Child Development Scheme (ICDS), Universal Immunisation Programme
(UIP), Oral Rehydration Therapy (ORT) } with wider coverage, regularity and better quality,
with special attention to girls and underprivileged social groups.
b) Empowering mothers and families with nutrition and health education, with emphasis on
caring for children and on low cost, locally available nutritious foods.
c) Control of iron deficiency anemia, Vitamin A deficiency and iodine deficiency.
lhe indirect, long term institutional and structural changes, as also recommended by the National
Nutrition Policy, 1993 would be sought to be implemented. These include:
(a) Improved food security
(b) Increased production of nutritionally rich foods such as pulses, oilseeds and ragi, and
protective foods such as vegetables, fruits, milk, poultry, fish and meat;
(c) Improved purchasing power by active implementation of poverty alleviation programmes;
' (d) Strengthening the public distribution system;
(e) Preventing food adulteration;
(1) Improving the status of women;
(g) Ensuring community participation
Imcgratcd Health Policy, Diaft.doc
16
5.12
Population Stabilization:
Population stabilization through fertility decline has long been a goal of the state government in
consonance with national priorities. It is, however, realized that some of the causes for the state
not achieving demographic goals as envisaged are inadequate social development isolation of
certain sub-groups of population .and lack of commitment on the part of service providers ft is
St'rVIf'AC "ifirl h.c olort
*J
I
g
d awareness, demand for
services and has also provided widespread access to contraceptive and family welfare services
especially terminal methods, and Mother and Child health care. There have been resultant gains
7 R rX"65 H
r>ateS 7 41<5 (195l'60) t0 22 0 (2000)’ death rates f10"’ 22 2 (1950-51 To
Ton i’ ru m
T fr,°m 22 (’951) t0 17 (2001 Census> The Total Fertility Rate (TFR)
2.13 and the effective Couple Projection Rate (CPR) is 60.7% (2001). Thus the State is fairlv
aZrT/sT in"8
decli"e ^owth rates, particularly
alter 1981 (in all districts except Gulbarga division with slower or stagnant declines) This
momentum of decline is likely to continue. Improvement in social development quahty ofTSe
and gender development will hasten the process of demographic transition. Tibs win be an
important component of the state strategy, with emphasis on districts in greater need.
^fiPSdPfel8bidelines of the National Population Policy 2000 tbe state wii1
?
“,d wi"
■■
*— *“■
»•
>■
It will pro-vidc good quality contraceptive services, integrated with primary health care
hroughout the State Reproductive technologies that are safe and effective will be used
Quahty of care will be further improved with screening, follow-up services, managing and
minimizing side effects Demand for spacing methods will be enhanced. Male methods wiU
be increasingly used reduemg the burden on women only. The government is committed to
providing for informed choices and to seeking the voluntary involvement of the citizens
’ ^°tndlnVO thC SPeCif'C situation in ^rnataka, the State will develop a special package for
districts with greatest unmet need in terms of Health and Family Welfare Services R will
endeavoiyo mcrease the utilization of these services by making them user friendiy. beTng
particularly sensitive to the special needs of women.
The objectives of the State in terms of population stabilization arc:
byO20108
•
the r°tal Fertili‘y Rate t0 replacement levels in the State and in all the districts
To achieve a stable population by 2030.
3
I
4
I
Iniejraled Health Policy_ Ontfl doc
17
Strategies:
1. The
'
need of Reproductive Child Health (RCH) services will be estimated through a
well-organized and meaningful Community Needs Assessment Approach at the grass
root level.
2. Setting up a State Commission for Population and Social Development.
3. Making all efforts to ensure adequate facilities for good quality mother and child
health care.
4. The State will attempt to develop a good civil registration system, working towards
100% registration of births, deaths. Registration of marriages will also be actively
promoted and gradually made compulsory.
5. The State is concerned about increasing son preference that is adversely altering the
gender ratio. It will implement legal measures such as The Prenatal Diagnostic
Techniques (Regulation and Prevention of Misuse) Act 1994 to prevent female
feticide. An awareness campaign would be mounted to educate the community
regarding the intrinsic value of girl children.
6. Introducing life-skill and population education for adolescent girls and boys, using
methods that capture their interest and responding to their needs.
7. Promoting delayed marriages for girls in particular and boys, delaying of the first
pregnancy and spacing of the second child.
8. A network of committed NGOs and other allied systems of medicine will be involved
in Needs Assessment and delivery of service.
9. macing
Placing tne
the responsibility ot
of implementing the Population Policy on a number of
y.
Departments, in addition to Health and Family Welfare through an effective inter
sectoral coordination mechanism.
10. Efforts will be made to enhance the adoption of family planning measures among
groups where fertility, due to various reasons, continues to be high.
11. All the districts, including those which are demographically advanced, will be given
due attention for sustaining the levels they have achieved.
12. Educational, vocational and employment opportunities for girls will be considerably
enhanced so that they become economically and socially empowered.
Plan of Action:
National Population Policy 2000 recognises the link between high infant mortality and
excessive population growth. A rapid reduction in neo-natal deaths is called for immediately.
Suitable strategies would be formulated for this purpose, including intensive training in care of
the new bom, and logistics and service interventions to rapidly bring down neo-natal deaths
and consequently infant mortality.
I
♦
Spacing of births has been very poor in the State. One of the reasons is due to inadequate skill
based training in I.U.D. insertion. Training strategy will be changed in the form of
decentralizing the training to Community Health Centre (CMC) / Primary Health Centre
(PHC) level so that hands-on training will be eflective and trained personnel available in
larger numbers.
,
Intcgrjtcd Health Policy_ Draft doc
18
♦
The injectable immunization services are not reaching certain remote pockets in the rural areas
and more so in the urban slums. Mechanisms will be devised to hire out the immunization
services to private clinical establishments on the basis of service charges and Anganawadi
Workers will also be involved with suitable training.
•
Focused “District Plans” will be prepared for those districts which are showing slow / poor
performance, implement and monitor the programmes towards achieving greater speed in
population stabilization.
•
Keeping in view the present demographic status and state’s financial and other capabilities,
realistic goals in respect of population, child health and maternal health at the end of 2010
will be worked out and necessary programmes will be taken up to achieve these goals.
5.12.1.
(a) The policy will address the increasingly adverse sex ratio. The Prenatal Diagnostic
Techniques (Regulation and Prevention of Misuse) Act 1994 would be strictly
enforced.
(b)The law relating to age at marriage would also be strictly implemented.
5.12.2
A special package for family welfare will be devised for the seven northern districts.
The unmet needs of the urban slums will be addressed with increased utilization of the health and
family welfare services by making them user friendly and sensitive to the special needs of women.
5.13
Education for Health Personnel
Karnataka has many achievements in the realm of education for health personnel, including
medical and all allied health professionals. Institutions of high quality have developed. The
private sector has been encouraged and a vast network of educational institutions has been
established: The relatively new Rajiv Gandhi University for Health Sciences is working towards
ensuring better academic and professional standards and norms.
Institutes and systems for education, training and continuing education play a critical role in the
formation of medical and allied professionals, and in the maintenance of tliis human resource as a
well-informed, up to date and motivated force. This is particularly important in a profession on
whose decision-making abilities and practices depend the life, health and well being of the people.
The regulation of the profession, including of its educational systems and institutions and the role
of the State therefore are issues of great importance.
, A situation analysis reveals many ills in the education system of health personnel, in the
institutions and in professional practice and conduct. These include a rapid expansion in quantity,
namely numbers of educational institutions and seats, at the expense of quality. In post
graduation, there is a mismatch between the specialties, with certain specialties remaining under
represented. Growing commercialization in the establishment and management of educational
institutions, decline in academic standards, dilution of professional standards and etliics are
identified as the specific areas that need to be addressed with concern.
bitepalcd Health Policy_ Dralt.doc
19
„
d ota facers » view, eer.ac peinCples and Cra.egiea for education for heaith
■
. The focus will be not only on -"X “ “i all allied health
. The functioning of a
professionals and on fndian Systems^f M d
health care services to respond
mi trakdng wdl be encouraged.
. Efforts will be made to improve the
institutions of all systems at Revels to br
h
norms laid down by
requirements of these
SEwilTte Z”or ensuring sustainabilily of these insirtulro^.
. in order to ensure quality, nonns
be respected, subject to any special ^ed®“Medical) Dental, Nursing, Pharmacy and
, SyTXTtS -m be critically viewed with tm exception for institutions m e
under-served areas of Karnataka.
M nnnlv for Ayurvedic, Homeopathic and Unani CoUeges in the
• Similar guidelines would apply tor y
’ State.
.
. Each Medical College will be required to take up some PHCs for traiubrg and servree
L? ■
. Tte para-medical Board Wdl strive to u—n standard of education h various Para-
:
Medical Diploma Courses.
. The standard of education In various Para-Medical Diploma Courses will be maintained.
'
Essential services win be mabttoined rotmd the clock C tire tcaciung hosp.ta.s,
.
.
E
. , ,
University, educational institutions
Closer working links will be
a^dWdevelopment. Health Service professionals
and health services for mutual adv
B
responsibilities, while a part of the teaching
may be permitted to undertake some teaclu g P
taJuk hospitals> as also
of undergraduates and P»
a“0 “n be exposed to Geld situations so that their
“XX-eh JuXof practical relev^e and taporiance.
ii
. improvements wid be ^de in .be P=bagogy of
—Jess'S
i
il
twi
r
i
and Para-Medical Board will organize
datory for teachers to undertake these
Methodology for health sciences It w 11 be m
ry
Each ^t^on
Xrses. Learner centered? proX: E -h^vith the specific objective to
will be encouraged to initiate and rui e<«
students will help to modify
Systematic
"”pro" XXeT’XorSX— of teaching facuity »iU help to further
develop their competence.
imcgrulcU llcdih Policy. DraA doe
20
•
I
State Councils such as Karnataka Medical Council, Dental Council, Nursing Council,
Pharmacy Council etc. will be strengthened and rendered more effective. The Committee
will develop good information and knowledge base to tlris end.
A Coordination Committee at the State level will bring together representatives from different
councils, including Indian Systems of Medicine and Homeopathy (ISM & H) along with
Government policy makers and University / Board representatives to address issues raised by the
National Education Policy for Health Sciences. The Committee would be alert to trends in the
sector including negative trends mentioned earlier and make suggestions for regulations and
correctives.
5.14
Rational Drug Policy
The State is aware of the technological advances and the progress in terms of
increased
increased
production, high turnover and exports made by the pharmaceutical industries in the country and
State.
The State will take steps to make available essential drugs of good quality in adequate
quantities in all Government hospitals and will take further necessary steps to curb the menace of
■spurious / adulterated/not of standard quality drugs.
The State will ensure compliance with the provisions of the Drugs and Cosmetics Act and Rules
and allied Drug Legislations.
The State supports the concept of essentiality, based on criteria of therapeutic needs, efficacy and
safety. Essential drug lists for different levels of institutions will be followed.
Dissemination of information on drugs concerning essentiality and essential drugs list to medical
professionals, pharmacists and to the citizens will be promoted. Patients right to information
about harmful, hazardous, irrational drugs will be ensured.
The State will continue to support the system of monitoring Ad verse Drug Rations (ADR) already
initiated by the Karnataka State Pharmacy Council.
i
The State will strengthen the Drug Control Enforcement machinery by providing adequate staff
with required qualification.
Key Staff and Doctors will be educated in rational use of Drug, and in Drug Policy Issues
Measures to increase efficiency, economy and transparency in drug procurement, warehousing
and distribution will be implemented.
■ The State will support strategies in co-ordination with professional and consumer bodies to ensure
safe drugs and rational use of drug for people.
A State drug formulary and therapeutic guidelines will be developed, adopted and regularly
updated.
21
Iiilcgfslcd Health Policy_ Diafl iioc
- ■ - ■w
analysis^ofdnig^611
5.15
m°deniize DrUgS TeStin8 Laboratories for speedy and accurate test' and
Blood Banks:
Availability of blood and blood components and functioning of blood banks will be improved
I reparation of blood components leading to better utilization of blood will be encouraged.
Medical Industry (diagnostics, biomedical equipment, health accessories)
5.16
The Health Department will lay down specific standards for procurement of medical and
diagnostic equipments, Health accessories and Health Education material.
internal mechanisms would be established, with expert assistance, to enable the formulation of
standards of equipment, the principles of maintenance and inspections and related issues.
Medical and Health Research
5.17
Karnataka State prides itself of having premier scientific, technical and research institutions in
various fields. The State will partner with these institutions and actively foster systematic data
collection and research in the public health services and educational institutions so as to inform
the planning process. It will develop the necessary bodies and facilities for this purpose A
research advisoiy group, within the Department, would steer the research process raise f^nds and
review technical quality and achievements.
d
5.18
Indian Systems of Medicine and Homeopathy (ISM AH)
The country and Karnataka have evolved and cherished a rich heritage of traditional Indian
^tcms of medicine and healing. These classical systems of Ayurveda, Siddha and Yoga have
die worlds earliest written texts and pharmacopia. They have survived through the centuries and
are currently gaining increasing global recognition and respect for their insights and holistic
approach to healing and efficacy. They have a large number of practitioners educSond
"jstitutmns, and pharmacies/centres where medicines are prepared. They are linked to local health
“,Ch “ U"ani’ Tii>e,a" mKliCin' 1"d
I
However, ISM&H has not received sufficient attention in health planning and resource
a option. These systems will receive increased support to promote their optimal growth They
“d ■”
tnlegralcd Health PoUcy_ Drafl.doc
»>2
22
5.19
-
Ueallli Proniotioi)
i|PrOdn° 8i
behaviOur chan8e and from bei,1g instructive to becoming empowering It
will address health determinants, disease prevention and control, using appropriate methods and
idioms to different settings and varied groups such as school children youTh women
workers/farmers etc It will enable people to increase control over and participate actively in
improving their health. Local folk media will be used.
The state will allocate adequate resources for health promotion and take measures to build
capacity for health promotion, using talent available from all sectors and promoting creativity
fntToiletlein08'311™65 n* ’
imPlemented activeIy including availability of drinking water
nd toilet facilities especially for girls. Health promotion measures would at all times take
advantage of teclinological advancements such as tele-medicine.
6. Policy Components on Priority Health Problems and Issues
6.1 Communicable / infectious diseases
ihrn
. W°U d h6.817611 t0 heaIth education aspects through field workers. This would be
eUnnl81 lnter’pe‘.sonal c,on.tact and grouP discussions, especially regarding personal hygiene and
n lo^SS -n
ar°Und
dwelling places- Th°ugh apparently simple, this message would go
a long way in prevention of communicable diseases, especially water borne diseases
8
Japanese Encephalitis:
Japanese Encephalitis being reported in some parts of the State during the post monsoon season
Regular surveillance and treatment activities are being carried out during the endemic season of
the disease. BeDary district is the most affected in the State. The other districts where the disease
occurs usually are Mandya, Kolar, Raichur and to some extent Bangalore Urban Chitradurea
Davanagere and Koppal. Entomological studies would be taken up intensively by the District
Surveillance Unit. Zilla Panchayats and NGOs would be involved in providing health education
to the population at risk, for prevention of man - mosquito contact, segregation^f pigs during the
epidemic season and rehabilitation of children affected by tins disease.
8
P8
6
-
The proposal for formation of a society for control of mosquito borne diseases is under the
co»,deration of Govermnent. Formation of society would eJUTe a„ Xamd
”aoi t
t vector control measures, with a common strategy.
• a) Tuberculosis:
In Revised National Tuberculosis Control T
Programme (RNTCP) the two
objectives of achieving 85% cure rate among new smear positive pulmonary TB
,
1 cases and case
detection of more than 70% of new smear —
.ar positive pulmonary cases after achieving cure rate of
85% have been incorporated with a view to rapidly reducing the incidence of TB in the
community.
Inicgraicd Health Policy_ DreA doc
23
Targets are fixed based on the annual risk of infection. The annual risk of infection at present is
1.7, which means that 85 positive cases per lakh occur in the community every year. Of this about
60% or 51 cases per lakh approach a health facility for treatment. All these cases have to be
identified, treated and cured. Hence the target of 50 per lakh positive cases or 59% of cases
would be sought to be achieved.
*
The two objectives have not been fully achieved since it is not possible to control all the factors
influencing the cure rate and case detection rate. However, it is assumed that as the programme
gets established and with improved awareness among the community, it would be possible to
achieve a higher case detection and cure rate over a period of 5- 10 years. In order to increase
the case detection rate to more than 70% it is necessary to involve all health institutions
(government / private / NGO) and all systems of medicine. The Revised National Tuberculosis
Control Programme (RNTCP) aims at this kind of expansion which will take some more time but
all necessary efforts for early achievement of these targets would be continuously sustained.
■
Attempting to improve case detection before achieving 85% cure will lead to unacceptably high
rate of mortality and drug resistance. It is also known that a good programme with high cure rate
will attract chest symptomatics for sputum examination, thereby increasing the case detection rate
to more than 70%.
In Karnataka, 4 districts have already crossed the target zone and are
detecting more than 70%. When once the incidence of new cases is controlled, the pool of cases
in the community would get gradually depleted.
Due to natural dynamics of TB, l/3rd of the
cases are removed every year due to death and spontaneous cure.
b. HIV/AJDS
lhe State will take proactive steps to create public awareness regarding this rapidly growing
problem. Preventive education will be undertaken among adolescents, workers in the organised
sector, women through Sanghas and women’s organisations. In particular, such preventive
education would include young adults. The general mass media would be intensively inducted for
this purpose.
Specific strategies would include the following District based Voluntary Counseling and Testing Centers (VCTC) will be established in all
district hospitals.
• Treatment to reduce mother to child transmission will be introduced.
• Home-based care would be encouraged and supported.
• There will be no discrimination in providing treatment facilities in ah public sector
hospitals. Private sector institutions will also be advised to be non-discriminatory
• Training of staff will be undertaken.
• Treatment facilities for Reproductive Tract Infections (RTIs) and Sexually Transmitted
Diseases (STDs) will be expanded, with conscious efforts to maintain privacy and
confidentiafity.
• Measures will be enforced to reduce transmission of HIV through blood transfusion and
blood products.
t
•
Iiacgraicd Health Policy_ Draft <k>c
24
•
‘
Strong advocacy and social mobilisation efforts will be made at all levels
pZ« md 0Per“ti°”i'1 reSearCh Wi" infOrn’ ““ euidc ,he d'™lopn>ent
* SiPS;Cp»°3“
of the
l° ™
■ s^sS’a“^rs.-;zxxsK=£
AIDS, orphaned children, abandoned patients, legal issues etc.
c) Vector borne diseases:
zx:
eartan^^^
«„»
dlelhyI
The increasing spread of dengue fever is recognized as a public health oroblem
Th»
K,h “T’ Pr°CKS wnl
•”
available ; be.ltI, Ppromotiong for
‘Xdif
dome^
reduce veelor breeding; adoption and implemematio/of X
XX “i
vector breeding grounds will be initiated.
’
nic,pal bye-laws to control
6.2
Women’s Health
The State has several ongoing schemes for girl children and
women. These will be expanded,
strengthened and developed further.
»orkpl«ee a„d in puMc phces.
-e'X;C™:Zit; XoSj’
Inlcgiated Health Policv Drafl doc
25
political participation which have positive influences. The State is committed to women friendly
policies in all these areas. It will also undertake reviews of the implementation of schemes
addressing these issues and studies of their impact with a view to improving the effectiveness of
these measures.
More specifically, in health, policies will work towards the following:
•
•
There would be a sustained focus on the entire life course or life cycle of women. This means
ensuring adequate nutrition and physical and social conditions for mothers during pregnancy,
providing access to good mother and child health services, implementing measures to prevent
female feticide and female infanticide.
Focus on the woman/women as a whole including physical, psychosocial and emotional
aspects.
Using strategies empowering women for health, where women are important agents for change.
•
Using a community health and community development approach that facilitates community
mobilisation, community participation, community orgamsation and community action,
wherein the role of men is also important. As many health problems of women have social
roots, this strategy will, allow for social interventions rather than medical interventions only.
•
Health promotion for women focusing on empowerment and community action.
Access to care for women will be enhanced by increasing the number of women health
professionals, particularly at primary care levels and in the first referral units. Provision of
adequate living facilities, equipment and drugs will also be ensured at these centres. Priority
attention will be given to backward areas.
•
Special attention will be given to developing counseling and mental health services for women,
with trained professionals and by short term training of health workers at primary care levels to
respond to the needs at community level..
•
Facilities for diagnosis and treatment of Reproductive Tract Infections (RTIs) and Sexually
Transmitted Diseases (SIDs) will be made available at the primary care level supported by a
referral system.
•
Education regarding reproductive health will be given high priority.
•
The health policies regarding women’s health would give emphasis to the following:
>
Women empowerment by providing more education and job facilities.
>
Male participation: As our society is male dominated, the need for male participation
in all spheres of women health would be stressed.
>
Grass root level workers, who are the back bone of these programmes, would be given
further training , facilities and incentives.
4
>
Intensive monitoring to ensure accountability at all levels would be introduced.
i
I
Iniegnitcd Health Policy, Drift doc
26
> Under Reproductive Child Health (RCH) - Intervention, by way of incentives, in UC’
category districts such as honorarium for doctors, nurses and cleaning personnel
conducting deliveries between 8.00 PM to 7.00 AM has resulted in an increase of
about 30% in institutional deliveries. Transport‘facilities for pregnant women requiring
referral to higher centers for safe delivery under RCH has also been perceived as
beneficial. It is proposed to continue these benefits.
6.3
Children's irealth
Karnataka State has a special interest in and commitment to the health and well being of children
during their intrauterine period, infancy, toddler years, school age and adolescence. Its
interventions reach out through Maternal and Child Health programmes, through Anganwadis of
the Integrated Child Development Scheme through schools and colleges. A policy document,
The State Programme of Action for the Child” brought out in 1994, reiterated the state’s
commitments, in keeping with the spirit of the National Policy for Children in 1974 the World
Summit for Children in 1990, the four sets of Rights of Children (to survival, ’ protection
development and participation), and the National Plan of Action: A Commitment to the Child,
adopted in 1992. The State will be guided by the principle underlying the national plan namely
first call for children”, wherein the essential needs of children will be given highest priority in
allocation of resources at all times. This will also be applied specifically to the spheres of health
and nutrition.
Specific efforts will be made to reach children, especially from socially deprived groups, who are
still not reached by the ICDS and who are out of school. A multi-sectoral approach will be used
to provide services for working and street children, and to address underlying issues that result in
their having to work.
•
The State will undertake all efforts to ensure cliild survival with no damage to the processes of
growth, maturation and development. Continuing efforts will be made to reduce infant and
neonatal mortality.
The coverage and quality of services of the Integrated Cliild Development Scheme (ICDS) with
regard to health, nutrition and care will be improved by providing adequate resources and training
of all levels of personnel.
Supervisory and monitoring systems will be strengthened
Constructive partnerships with gram Panchayats and parents will be developed and linkages with
Primary Health Centre staff will be made more functional and regular. Quality of food given to
children will be ensured and health promotion and nutrition education will be undertaken more
proactively.. The most needy children, including those belonging to scheduled castes and
scheduled tribes, will receive particular attention.
Mental Health
6.4
i
The burden of suffering due to mental illness is high. Research work done over the years by
• premier institutions has helped to quantify this in Karnataka. At least 2% of the population suffers
from severe mental morbidity at any point of time and an additional 10% suffer from neurotic
conditions, alcohol and drug addictions and personality problems. A
/. 1large proportion of
outpatients (20-25%) in general health services has somatoform disorders and
J come with multiple
bnccralcd tleaflb Policy_ Draft doc
27
vague symptoms. Unsupported and untreated mental illness has an impact on families as well.
Mental ill health is thus an issue of public health importance, requiring proactive, sensitive
interventions, particularly since more effective and better management is now a reality.
However, there continue to be shortages of tramed personnel in Karnataka, compounded by
misdistribution of facilities and staff with a greater urban concentration, especially in big cities.
The state will make systematic and sustained efforts to enhance mental health services by:
•
Improving training in psychiatry and psychology in the undergraduate medical and general
nursing courses.
•
Introducing district mental health programmes in a phased manner by strengthening psychiatric
teams and services at district hospital level and planning for counseling services at taluk
hospital level.
•
Ensuring minimum standards of care for mentally ill patients.
•
Providing for mental health care at primary care level by training primary health centre medical
officers and staff, using manuals already prepared by National Institute of Mental Health &
Neuro Sciences (NIMHANS).
•
Encouraging and making provision for care facilities for persons with chronic mental illness,
through NGOs and other organizations.
•
Introducing the mental health component into school health services on a pilot basis in
different districts and later expanding it.
•
Supporting broader societal strategies that address violence, particularly against women’
discrimination in any form; substance abuse; poverty and destitution.
•
Establishing institutional mechanisms at the State level through which mental health care
services can be promoted.
•
Caring for and nurturing health care personnel, who work under difficult conditions.
I-......
6.5
Prevention and control of non-coninninkahle diseases
Karnataka carries a double burden of communicable and non-communicable diseases. The latter
, include, in particular cardiovascular diseases, including hypertension, cancers and diabetes. These
have on the whole received less public sector and policy attention due to the magnitude of other
problems and issues. However, keeping in view the future perspective, especially considering
' rising life expectancies, growing urbanisation and industrialisation in the state, and rapidly
changing life styles including diets, the state will provide greater support to the prevention and
control of non-communicable diseases.
,
biicgiatcd Health Pol>cy_ Draft doc
28
-
®
It will use a public health approach by adopting strategies to reduce the risk factors for these
diseases and by using health education to promote healthier life styles.
•
It will initiate policies to discourage the use of tobacco and alcohol, which is on an increasing
curve due to intensive advertisement and aggressive marketing. Over 25 serious diseases are
associated with the use of tobacco and several diseases and social problems are linked to
alcohol. These are described as communicated diseases. They are both addictive substances..
Policies that would reduce consumption of these include bans on sponsorship of sports and
entertainment; bans on direct and indirect advertising; higher taxation; sales to be permitted to
persons over 18 years; sales to be barred within certain distances from educational institutions;
and public education, especially among children and youth as part of life skills education;
education of health personnel.
In the case of tobacco, measures include banning smoking in public places to prevent passive
smoking and working towards alternative crops and alternative employment for those engaged in
its cultivation and production. Chewed tobacco in particular is a growing problem with
widespread use among women (40-60% in different groups) and even among children as its
addictive nature is not widely known. Comprehensive tobacco control includes smoked and
chewed tobacco. The appropriate measures would be taken to the extent feasible to mitigate the
use of tobacco.
In the case of alcohol there is a need for strategies to help women and children cope with men
who drink heavily. De-addiction strategies using group therapy such as alcoholic anonymous
groups will be supported, besides individual therapy and counseling.
. Education regarding the deleterious effects of tobacco and alcohol will be included in school and
college curricula.
•
Diagnosis and treatment for non-communicable diseases will be made available at primary
health care level. This will require preparation of treatment guidelines and supply of diagnostic
equipment and drugs.
•
Recording and reporting of non-communicable diseases as per the International Classification
of Diseases will be introduced into the diseases surveillance system.
•
The cancer control programme will also be strengthened by discouraging the use of tobacco,
health education, early detection and provision of treatment. Facilities will be made available at
regional level and later in a phased manner in some districts where medical colleges exist.
Grants provided by the national programme will be fully utilised.
, 6.6
Disability
It is estimated that about 2% to 3% of the total population of Karnataka consists of persons with
disabilities, with 76% in rural areas and 58% men. Disabilities include locomotor, visual and
learning disabilities, hearing and speech impairment, mental illness, mental retardation, multiple
disabilities, leprosy cured with disability etc.
luicgraied Health Polic>_ Draft.doc
29
An inclusive approach will be adopted for persons who are differently challenged or persons with
disability, with their full participation in decision-making and implementation.
1 he Department of Health and Family Welfare will increase its role and responsibility in respect
to disability, by way of prevention, early detection and intervention and will, for this purpose
coordinate with the Directorate of Welfare of the Disabled, under the Department of Women and
Child Development, which is currently the administrative Department concerned.
The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation)
Act 0 , 1995 wil1 be made more widely known and implemented. Interventions will include
medical, social and environmental components. The different steps would be:
•
Disability prevention - through universal immunization, good nutrition, Maternity & Child
Health, accident prevention through “drink and not drive” poheies, helmets for two wheelers
and car-seat belts etc.
•
Disability limitation - through prompt treatment, particularly at primary care levels.
•
Reducing the transition from disability to handicap
rehabilitation units at district hospitals.
by rehabilitation. Establishing
Actively supporting Community Based Rehabilitation.
•
Providing access to aids and appliances to those who cannot afford them.
•
Using apex and specialized institutions in the state for training of Medical officers and different
levels of health workers.
•
As per the Medical Council of India recommendations, starting Physical Medicine and
Rehabilitation departments in every medical college.
6.7
Occupational Health ami Safety
Though services exist in some large public sector and private sector units, this specialty needs
greater support. The focus will be on the workers in the agricultural and unorganised sectors who
comprise the largest proportion of the work force and who are at risk because few safety devices
and precautions are used. The services of institutions like the Regional Occupational Health
Centre and experts will be utilised to evolve a strategy.
'
6.8 Dental Health/Oral Health
i
r
The awareness about dental health care is poor especially in rural areas. The increased life
expectancy of the population and widespread prevalence of oral diseases warrants a serious
. thought for immediate strengthening of the.existing oral health delivery system in the State.
luiegraicd Health Policy_ Draft doc
30
I he establishment of a three tier Oral Health Care delivery system in Karnataka would be
planned, namely:
1) Primary Oral Health Care
2) Secondary Oral Health Care
3) Tertiary Oral Health Care
Primary Oral Health Care comprises of mainly (a) Health Education for promotion of oral health
and (b) various Preventive Procedures for Oral Health. Secondary Oral Health Care comprises of
Secondary level Oral Health care given by qualified dental surgeons at Community Health
Centres and Taluk level Hospitals. The Secondary Oral Health care rendered at these hospitals
includes both Preventive and also Curative treatments. The Tertiary Oral Health Care programme
comprises of specialty treatment, which will be made available at each District level Hospital.
Necessary restructuring of the implementation, monitoring and supervision mechanisms for these
programmes within the Department would be made.
Other strategies would include • Proper utilization of mass media for regular Oral Health Education
• Involvement of local non-governmental agencies in programme operation for better
implementation of the programme
• Programme for increasing awareness amongst School teachers regarding Oral Health.
Apart from the Government Dental College, Bangalore, other good Dental Colleges in each
division would be identified so that such colleges, dental associations and other social
organizations adopt some villages for comprehensive dental care delivery.
6.9
Emergency Health Services and Trauma Care
There is a pressing need for strengthening and expanding Emergency Health Services and
Irauma Care. This would include not only accidents and injuries but also Emergency Obstetric
Care (EOC), snakebites, dog bites, insect stings and other medical emergencies. The timely
availability of Anti-Snake Venom, antidote for Organo phosphorus poisoning and anti Rabies
vaccine will be ensured. Networking of Communication, links and transport facilities will be
established.
Training in first-aid and life support systems will be imparted to school children, college
students, teachers, factory workers, drivers, bus conductors, traffic police and paramedics.
Efforts will be made to enforce preventive measures such as wearing of helmets and seatt belts.
The Citizens Right to accessing emergency care for first line critical care in any hospital,
as determined by the Supreme Court, will be widely publicised.
!nlcgrated Health Policy_ Draft doc
31
F
7.
Cross-cutting Policy Issues
7,(
Medical and Public Ileahh Ethics
Admittedly, there is considerable scope for improving the efficiency of the public health
services and for enhancing the level of confidence in these services. Concerns regarding the
current levels of adequacy, acceptability, quality, performance and accessibility of the public
health services are reflected in the Report of the Task Force on Health and Family Welfare.
Necessary structural changes in the system and appropriate institutional and procedural changes
for correcting these observed deficiencies would be instituted.
k
•
The state will promote the principles and practice of medical ethics in all its institutions, in all
health sectors and in all systems of medicine.
•
The primacy of public health will be restored and the principles and ethics of public health
would form the core of the public health services, while maintaining the necessary attention to
and level of clinical services.
A
I?'.
■■
I- .
’
7,2
Community Participation and the Role of the Panchayat Institutions
Health and its related sectors such as sanitation and drainage, nutrition, safe drinking water
practices and the like are doubtless the primary responsibility of the State. However, by their very
nature, the successful implementation of programmes in these areas would be heavily dependent
on the involvement of the both the community and the individual families. It is essential,
therefore, to ensure the cooperation and involvement of the community in the processes of
planning, implementation and monitoring of health services. Such community participation would
be through involving and assigning responsibilities to NGOs, voluntary social organisations such
as Mahila Mandals, Youth Clubs and the like. Mechanisms would be developed for the active
involvement of these local community organisations.
In tills context, it is recognised that the Panchayati Raj institutions have a major role in the
provision and management of health services. They have a statutory responsibility in this matter
and all assistance and encouragement would be given to the Panchayati Raj institutions to
discharge this responsibility to the satisfaction of the people they represent. Necessary
mechanisms for training the members of these institutions, monitoring performance and providing
both technical and management expertise would be developed. It is recognised that the State
shares, with these institutions, this responsibility of providing adequate health services.
7.3
Institutional Structure lor Implementation
Implementation of this Health Policy would imply that necessary structural changes are
made within the health services themselves and, towards this end, the reorganisation of the
Directorate of Health Services has already been instituted. However, the Health Policy does not
stand-alone. It has to be consistent with and integrated into policies that deal with development
Imcgmcd Health Policy_ Dra/1 <!oc
2
sectors related to health. This, it is recognised, would be effectively possible only through a high
level mechanism that would oversee and coordinate these various sectors. It is, therefore,
envisaged tliat-
•
At the State level, a Commission on Population and Social Development would be
constituted for consideration of all policy and coordination issues relating to the social
sectors of development, including health, with the Chief Minister as Chairman, and would
include the Ministers concerned with Health, Finance, Medical Education, Social Welfare,
Women and Child Development, Education, Rural Development and Panchayati Raj and
other related development sectors as may be appropriate, and experts.
•
At the apex administrative level, Committee on Population and Social Development would
be constituted with the Chief Secretary /Development Commissioner as Chairperson and
including the Principal Secretaries of the Departments of Finance, Health, Education,
Social Welfare, Women and Child Development, Rural Development, and other concerned
Departments. This Committee would be responsible for planning, monitoring and
coordinating the activities of these related social sectors, including health;
• The review mechanisms in the Zilla Panchayats and the other Panchayati Raj institutions
would be strengthened towards ensuring effective, coordinated implementation of health
services.
• Inputs from the health sector would be built into all development programmes to ensure
maintenance of public health standai ds.
8.
CONCLUSION
This policy document is just one step in the overall ongoing policy process that makes
explicit the current concerns, intentions and priorities concerning health.
The confidence evoked in the public by those who manage and deliver health services is critical in
transforming policies and programmes into action for social good. It is recognised that there are
conflicting interests in the provision of any social service, including health, which often result in
pressure groups and inliibiting factors in implementation. However, it is reiterated that the only
criterion that would imbue the health services would be the larger public good. The improvement
mid enhancement of health services would be guided by tliis sole principle.
In conclusion, through tliis policy document Karnataka state is placing health high on its agenda.
It reaffirms the wisdom of the sages who said that health is wealth. It will translate this into
action by allocating adequate human and financial resources, by good governance and institutional
capacity building. “Better health for all now” can only be achieved if it is seen as a common
endeavor of all sections of society. The state will play a facilitating role in harnessing resources,
energies and ideas from the private and voluntary sector. It will stay committed to its mandate
and will work towards equity, integrity and quality in health and health care.
Ittlcgrated Health Policy_ Draft doc
33
- Media
RF_HP_2_A_SUDHA.pdf
Position: 756 (9 views)